THE  LIBRARY 

OF 

THE  UNIVERSITY 
OF  CALIFORNIA 

LOS  ANGELES 


GIFT 

B.  Zeran 


THE  PRACTICAL  APPLICATION 


RONTGEN  RAYS 

IN 

THERAPEUTICS 
AND  DIAGNOSIS 


WILLIAM  ALLEN, PUSEY,  A.M.,  M.D. 

Professor  of   Dermatology  in  the  University  of  Illinois;    Member  of  the  American 
Dermatological  Association 


EUGENE  WILSON  CALDWELL,  B.S. 

Director  of  The  Edward  N.  Gibbs  X-Ray  Laboratory,  University  and  Bcllevue  Hospital 

Medical  College,  New  York;   Member  of  the  Rb'ntgen  Society  of  London; 

Associate  Member  of  the  American  Institute  of 

Electrical  Engineers 


HUustratefc 


PHILADELPHIA,  NEW  YORK,  LONDON 

W.  B.   SAUNDERS   S   COMPANY 

1903 


COPYRIGHT.  1903,  BY  W.  B.  SAUNDERS  &  COMPANY 


REGISTERED  AT  STATIONERS'  HALL,  LONDON,  ENGLAND 


WN 
ZOO 


1903 

CONTENTS. 


PART  I. 
X-RAY  APPARATUS  AND  ITS  USE  IN  DIAGNOSIS. 

INTRODUCTION    PA17 

CHAPTER  I. 

THE  ESSENTIALS  OF  AN  X-RAY  EQUIPMENT 21 

Influence  Machines,  22 — Induction  Coils,  22 — High-frequency  Coils, 
24 — Available  Sources  of  Electrical  Energy,  24 — Fluorescent  Screens 
and  Photographic  Plates,  27. 

CHAPTER  II. 

X-RAY  TUBES 28 

General  Properties  of  Tubes,  29 — Definition,  29 — Penetration,  30 — 
Production  and  Dissipation  of  Heat  in  Tubes,  31 — Operation  of  the 
Tube,  33 — Temperature,  34 — Clamping  the  Tube,  34 — Connecting 
Wires,  34— Punctures,  37— Testing  the  Tube,  38— The  Choice  of  an 
X-ray  Tube,  43— Bi-anode  Tube,  44— Penetrator  Tube,  45— Tubes 
with  Vacuum  Regulators,  45 — Thomson  Tube,  45 — Bario-vacuum 
Tube  and  Regulator,  46 — Sayer  Tube,  46 — Miiller's  Regulating 
Tube,  49 — Tubes  with  Osmosis  Regulators,  50 — Hirschmann's  Tube, 
51— Water-cooled  Tubes,  52— Tubes  with  Heavy  Targets,  52 — 
Double-focus  Tubes,  54 — Tubes  for  Therapeutic  Uses,  55. 

CHAPTER  III. 

INDUCTION  COILS,  INTERRUPTERS,  AND  THEIR   MANAGE- 
MENT           60 

Induction  Coil,  60 — Winding  of  the  Primary,  60 — Insulation  be- 
tween the  Primary  and  Secondary,  61 — Insulation  of  the  Secondary 
Winding,  62 — Insulation  of  the  Secondary  Terminals,  63 — Break- 
down in  Coils,  63 — Requirements  of  an  Induction  Coil  for  X-ray 
Work,  64 — Interrupters,  65 — Vibrating  Interrupters,  67 — Rotary 
Interrupters,  70 — Mercury  Interrupters.  73 — Turbine  Interrupters, 
"5 — Electrolytic  Interrupters,  78— Condensers,  85 — -Rheostats, 
86 — Switches,  87 — Fuses,  87 — Meters,  88 — Induction  Coil  Instal- 
lations, 90 — Portable  X-ray  Apparatus,  93. 

CHAPTER  IV. 

STATIC    MACHINES    AND    THEIR    MANAGEMENT 98 

Size  of  Machine,  103 — Hard-rubber  and  Mica  Plates,  104 — Regu- 

7 


8  CONTEXTS. 


PAGE 


lating  the  Discharge,  104 — Enclosing  Case  for  Static  Machine,  106 — 
Ozone  and  Nitrogen  Oxids,  106 — Disturbing  Effects  of  Moisture, 
107— Oiling  the  Machine,  107— Series  Spark  (lap,  108— Polarity, 
108. 

CHAPTER  V. 

FLUOROSCOPY     100 

Limitations  of  Fluoroscopic  Examinations,  109 — Apparatus  for 
Fluoroscopy,  109 — Series  Spark  Gap,  110 — Fluoroscopes  and  Fluor- 
escent Screens,  112 — Adjustable  Diaphragms,  116 — Guarding 
against  Over-exposure,  116 — Screens  for  Preventing  Burns,  117 — 
Importance  of  Proper  Relation  of  Fluoroscope,  Tube,  and  Patient, 
117 — Fluoroscopic  Examinations  of  Head,  Face,  and  Neck,  117 — 
Shoulder,  118 — Extremities,  118 — Thorax,  119 — Abdomen  and 
Pelvis,  121 — Location  of  Foreign  Bodies  with  the  Fluoroscope,  121 
— Shenton's  Method,  122 — Stereo-fluoroscopy,  124. 

CHAPTER  VI. 

RADIOGRAPHY 123 

Exciting  Apparatus,  128 — Duration  of  Exposure,  131 — Distance 
of  Tube  from  Plate,  132 — -Clothing,  132 — Radiographing  Botli  Sides 
for  Comparison,  132 — Bandages,  Splints,  Plaster  Casts,  etc.,  133 — 
Diagnosis  of  Malignant  Growths,  133 — Marking  the  Skin,  133 — 
Tubes  for  Radiographic  Work,  133 — Definition,  134 — Secondary 
Rays,  134— Degree  of  Penetration,  134— Tube-holders,  135— Tables, 
138 — Envelopes  and  Plate-holders,  141 — Intensifying  Screens,  143 — 
Prevention  of  Movement  during  Exposure,  144 — Importance  of 
Correct  Pose,  146 — Examining  the  Negative.  140 — Illuminating 
Device,  146 — Marking  the  Negatives.  148 — Record  Book,  150 — 
Preserving  the  Negatives,  156 — Upper  Extremity,  157 — Elbow,  158 
—Arm,  160— Shoulder-joint,  160— Scapula,  162— Clavicle,  162- 
Foot,  165— Medio-tarsal  joint,  165— Ankle,  165— Leg,  166— Knee- 
joint,  16Q— Thigh,  170— Hip-joint,  170— Head,  Face,  Neck,  171— 
Face,  173— Teeth,  173— Neck,  174— Thorax,  174— Position  of  the 
Patient,  175 — Esophagus,  176 — Spinal  Column,  176 — Lumbar  Ver- 
tebrse,  176 — Abdomen  and  Pelvis,  177 — Stones  in  the  Bladder,  178 — 
Stones  in  the  Kidneys  and  Upper  Part  of  Ureters,  178 — Gall-stones, 
180 — Localization,  183 — Stereoscopic  Radiographs,  190 — Interpre- 
tation of  the  Negative,  194. 

CHAPTER  VII. 

THE    PHOTOGRAPHIC  MATERIALS  AND  THEIR  MANIPULA- 
TION    195 

Plates,  195— Size  of  Plates,  197— Keeping  the  Plates,  197— Develop- 
ers, 197— Developing  the  Plates,  200— Fixing  Baths,  201— The 
Dark  Room,  202— Rubber  Gloves,  204— Printing,  204. 

CHAPTER  VIII. 

THE    CHOICE    OF    AN    X-RAY   OUTFIT 208 

Apparatus  for,  210 — Volt   Direct  Current,   209 — For  Alternating- 


CONTEXTS.  9 

PAGE 

current  Circuits,  211 — When  no  Lighting  or  Power  Circuit  is  Avail- 
able, 213 — Selection  of  Tubes,  214 — Accessory  Appliances,  215. 


PART  II. 
THE  THERAPEUTIC  APPLICATION  OF  X-RAYS. 

CHAPTER  I. 

THE    EFFECTS    OF    X-RAYS    ON    TISSUES 221 

Gross  Effects  upon  Tissues,  221 — Pigmentation,  222 — Dermatitis, 
223 — After-effects  on  the  Skin,  225 — Burns  Involving  the  Subcuta- 
neous Tissue,  225 — Extent  of  Burns.  Pain.  Scars,  226 — Chronic 
X-ray  Dermatitis,  229 — Hyperkeratosis,  229 — Changes  in  the  Ap- 
pendages of  the  Skin,  230 — Deep-seated  X-ray  Effects,  231 — Time 
of  First  Appearance  of  Symptoms,  234 — Duration  of  X-ray  Burns, 
236— Relapses,  238— Cumulative  Effects,  239— Idiosyncrasies,  239 
— Question  of  Dangerous  and  Safe  Exposures,  241 — Influence  of 
Various  Factors  on  Susceptibility,  245 — Immunity,  245 — Anodyne 
Effect  of  X-rays,  246. 

CHAPTER  II. 
THE  HISTOLOGICAL  CHANGES  PRODUCED  IN  TISSUES  BY 

X-RAYS   249 

Alopecia  in  Guinea-pigs,  250 — Epidermis,  250 — Hair  and  Sebaceous 
Follicles,  251 — Cutis,  251 — Microscopic  Changes  in  Psoriasis  under 
X-rays,  259 — Microscopic  Changes  in  Lupous  Tissue,  260 — Lepra, 
263 — Changes  in  Carcinomatous  Tissue  under  X-rays,  263. 

CHAPTER  III. 

THE   EFFECT   OF   X-RAYS   ON   BACTERIA 27S 

The  Effect  of  X-rays  on  Bacteria  in  Cultures,  278 — Effect  of  X-rays 
on  Bacteria  in  Living  Tissues,  283. 

CHAPTER  IV. 
THE  CAUSES  OF  THE  PHENOMENA  OBSERVED  IN  TISSUES 

AFTER    EXPOSURE    TO    X-RAYS 286 

What  is  the  Active  Agent  in  the  Production  of  the  Tissue  Changes 
Following  X-ray  Exposures?  286 — What  is  the  Property  in  X-rays 
that  Affects  Tissues?  292. 

CHAPTER  V. 
THE  TECHNIQUE  OF  X-RAY  EXPOSURES  FOR  THERAPEUTIC 

PURPOSES 302 

Kienbock's  Technique,  302— Scholtz's  Technique,  305— Oudin's 
Recommendations,  306 — Williams'  Technique,  306 — Beck's  Tech- 
nique, 307— Schiff  and  Freund's  Technique,  308— Factors  Affect- 
ing the  Quality  of  X-rays,  308 — Standard  Light,  309 — Influence 
of  Amperage  and  Voltage,  310 — Quality  of  Tubes,  310 — Duration 


10  CONTENTS. 

PAGE 

and  Distance,  311 — Frequency  of  Exposure,  311— Preliminary 
Exposures  to  Determine  Susceptibility,  311 — Distance  of  Tube, 
311 — Record  of  Exposures,  312 — Necessary  Apparatus,  312 — How 
far  should  X-ray  Effects  be  Carried?  314 — Apparatus,  317 — Coils 
vs.  Static  Machines,  317 — Coils,  319 — Source  of  Energy,  319 — 
Meters,  319— Interrupters,  320— Tube-holders,  320— Tubes,  321— 
Protectives,  325 — Masks  for  Special  Parts  of  the  Body,  327 — Alu- 
minum Screens,  329 — Insulation  of  Patient,  330. 

CHAPTER  VI. 

TREATMENT   OF   X-RAY   BURNS 331 

Care  to  Avoid  Burns  in  X-ray  Workers,  334. 

CHAPTER  VII. 
INDICATIONS  FOR    THE  THERAPEUTIC  USE  OF  X-RAYS   .    335 

CHAPTER  VIII. 

AFFECTIONS  OF  THE  APPENDAGES  OF  THE  SKIN 339 

Hypertrichosis,  339 — Alopecia  Areata,  349 — Tinea  Tonsurans  and 
Favus,  350 — Sycosis,  351 — -Acne  Vulgaris  and  Comedo,  352 — Rosa- 
cea  361 — Hyperidrosis,  362. 

CHAPTER  IX. 

INFLAMMATORY   DISEASES   OF   THE   SKIN 303 

Eczema,  363 — Psoriasis,  365 — Lichen  Plan  us,  367 — Lupus  Erythem- 
atosus,  368 — Prurigo  and  Urticaria  Pigmentosa,  370. 

CHAPTER  X. 

TUBERCULOSIS  AND  SIMILAR  DISEASES    371 

Lupus  Vulgaris,  371 — Tuberculous  Ulcers  and  Scrofuloderma,  390 — 
Tuberculous  Vesical  Fistula,  393 — Tuberculosis  of  Glands,  393 — 
Tuberculosis  of  Larynx,  395 — Tuberculosis  of  Joints,  395 — Tubercu- 
losis of  Genito-urinary  Tract,  396 — Abdominal  Tuberculosis,  396 — 
Pulmonary  Tuberculosis,  397 — Syphilis,  398 — Leprosy,  399 — Actino- 
mycosis,  399 — Blastomycosis,  399. 

CHAPTER  XL 
CUTANEOUS  CARCINOMA 403 

CHAPTER  XII. 

CARCINOMA  OF  THE  BREAST  AND  IN  THE  THORAX 468 

Carcinoma  of  the  Breast,  468 — Recurrent  Carcinoma  of  the  Breast, 
470 — Summary,  492 — Primary  Carcinoma  of  the  Breast,  493 — Sum- 
mary, 497 — Mediastinal  Tumors,  499 — Carcinoma  of  the  Esopha- 
gus, 500. 

CHAPTER  XIII. 

DEEP-SEATED  CARCINOMA 502 

Deep-seated  Carcinoma  of  the  Head  and  Neck,  502 — Carcinoma  of 
Neck,  502 — Conclusions,  505 — Carcinoma  of  Mouth  and  Pharynx, 


CONTENTS.  11 

PAGE 

506 — Dee])  Carcinoma  in  the  Orbit,  507 — Carcinoma  in  the  Abdo- 
men, 509 — Carcinoma  in  the  Pelvis,  510 — Carcinoma  of  the  Anus 
and  Rectum,  513. 

CHAPTER  XIV. 

SARCOMA   AND   OTHER   GRANULOMATA 514 

Sarcoma,  514 — Sarcoma  of  Parotid,  523 — Sarcoma  of  the  Eye,  530 
— Mycosis  Fungoides,  531 — Granuloma  of  Uncertain  Character,  531. 

CHAPTER  XV. 
THE  PROPHYLACTIC  USE  OF   X-RAYS  AFTER   OPERATIONS 

FOR  MALIGNANT    DISEASES 53<S 

The  Use  of  X-rays  Preliminary  to  Operation,  541. 

CHAPTER  XVI. 
PSEUDO-LEUKEMIA,  AND  VARIOUS  OTHER  AFFECTIONS  .  .    542 

Pseudo-leukemia,  542 — Leukemia,  552 — Neuralgias,  556 — Rheu- 
matism, 557 — Pruritus,  557 — Goitre,  558 — Scars,  558 — Elephan- 
tiasis, 560 — Callous  Sinuses,  560 — Chronic  Ulcers,  560 — Naevus,  560 
— Vascular  Nsevi,  565 — Verruca,  566 — Clavus,  566 — Senile  Verruca, 
566— Leucoma,  566. 

CHAPTER  XVII. 

GENERAL  CONCLUSIONS   567 

Non-malignant  Diseases,  567 — Malignant  Diseases,  568 — Prophy- 
lactic Use  of  X-rays,  570 — Use  of  X-rays  Preliminary  to  Operations, 
570— Permanency  of  Results,  570 — Length  of  Treatment  of  Success- 
ful Cases,  571 — Reasons  for  Different  Results  in  Similar  Cases,  571 — 
Effect  of  X-ray  Exposures  on  General  Health,  572 — Effects  on  the 
Blood,  573 — Danger  of  Metastasis  Under  X-ray  Exposures,  574 — 
Use  of  Other  Treatment  in  Conjunction  with  X-rays,  575 

INDEX  577 


PART  I. 

X-RAY  APPARATUS  AND  ITS  USE  IN 
DIAGNOSIS. 


BY 

E.  W.  CALDWELL. 


PREFACE  TO  PART  I. 

IN  the  seven  years  that  have  elapsed  since  the  discovery  of 
the  x-ray  very  little  has  been  added  to  our  knowledge  of  the 
pure  science  of  the  subject  beyond  what  is  set  forth  in  Rontgen's 
classical  papers. 

The  art  of  applying  these  rays  in  medicine  and  surgery  has 
steadily  advanced,  and  valuable  improvements  in  methods  and 
appliances  have  been  made  by  many  enthusiastic  workers  in 
every  part  of  the  civilized  world. 

In  the  pages  that  follow  I  have  not  attempted  to  describe 
all  the  valuable  work  that  has  been  done  with  the  x-ray  in 
diagnosis,  but  to  present  in  a  brief  but  fairly  comprehensive 
way  the  methods  and  the  various  forms  of  apparatus  with  which 
the  best  results  have  been  achieved.  I  have  given  special  at- 
tention to  many  of  the  details  which  make  up  a  good  practical 
technique,  and  have  devoted  considerable  space  to  the  dis- 
cussion of  x-ray  apparatus  and  the  methods  of  using  it. 

There  is  a  tendency  among  medical  men  either  to  under- 
estimate the  value  of  the  x-ray  as  an  aid  to  diagnosis  or  to  fail 
to  appreciate  its  limitations.  I  have  therefore  tried  to  show 
in  a  conservative  way  just  \vbat  may  and  what  may  not  be 
accomplished  with  it  in  the  present  state  of  the  art. 

Among  those  who  are  actively  engaged  in  x-ray  work  there 
is  a  great  diversity  of  opinion  as  to  what  type  of  apparatus 
and  what  methods  of  procedure  are  best.  These  varying  opinions 
result  largely  from  the  fact  that  excellent  work  has  been  done 
with  almost  every  known  type  of  apparatus.  I  have  tried  to 
discuss  impartially  the  merits  of  the  (Afferent  appliances  em- 
ployed in  x-ray  work,  and  to  show  what  types  are  best  suited 
for  the  different  kinds  of  work  and  the  various  conditions  of 
current-supply.  In  doing  this  one  must  necessarily  make 
statements  which  are  more  or  less  dogmatic,  and  in  which  the 

15 


16  PREFACE. 

''personal  equation''  is  an  important  factor.  I  have  not  hesi- 
tated to  express  my  convictions  freely,  although  some  of  them 
are  not  in  accord  with  commonly  accepted  views. 

The  indications  which  the  x-ray  gives  of  pathologic  condi- 
tions of  the  thoracic  region  is  a  large  subject  by  itself,  and  has 
been  ably  discussed  by  many  writers  who  are  familiar  with 
its  medical  aspects.  I  have  therefore  felt  unable  to  do  more 
than  refer  to  their  work  and  to  tell  how  the  examinations  are 
made. 

The  discussion  of  the  elementary  principles  of  electricity  and 
the  description  of  simple  electrical  apparatus — batteries,  electro- 
magnets, etc. — are  for  a  similar  reason  omitted  from  these  pages. 

In  preparing  this  work  I  have  gathered  ideas  from  most  of 
the  existing  books  on  the  subject,  and  have  contributed  such 
of  my  own  original  work  as  seems  to  have  an  established  prac- 
tical value. 

I  am  indebted  to  Dr.  J.  Mackenzie  Davidson,  Dr.  AY.  Y. 
Cowl,  Dr.  Grunmach,  Dr.  E.  AY.  Shenton,  Dr.  F.  H.  Williams, 
Dr.  A.  B.  Johnson,  and  others  eminent  in  .r-ray  work  for  courtesies 
extended  to  me  in  connection  with  their  various  developments 
of  the  art.  To  the  founders  of  the  Edward  X.  Gibbs  -Y-ray 
Laboratory  I  am  indebted  for  rare  opportunities  for  observa- 
tion and  experiment  in  this  fascinating  field. 

E.  W.  CALDWKLL. 

Xtn-  York.  A j, ril.  1'.  </>.;. 


INTRODUCTION. 


PROBABLY  the  first  x-rays  were  produced  by  Crookes  in  his 
experiments  on  electrical  discharges  through  vacuum  tubes 
in  1875.  He  did  not  recognize  the  x-ray,  and  for  twenty  years 
following  these  experiments  it  remained  unnoticed,  and  almost 
unsuspected. 

In  1893  and  1894  both  Herbert  C.  Jackson,  of  King's  College, 
London,  and  Professor  Lenard  came  very  near  making  the 
great  discovery.  It  remained,  however,  for  Professor  Wm. 
C.  Rontgen,  of  Wiirzburg,  to  bring  these  rays  from  their 
hiding-place  and  give  us  some  clue  to  their  nature. 

The  study  of  the  history  of  electrical  discharges  in  rarefied 
air  and  gases  leads  us  far  back  toward  the  beginning  of  the 
nineteenth  century,  but  it  was  not  until  1858-1859  that  Geissler 
made  the  first  vacuum  tubes.  These  tubes  were  of  compara- 
tively low  vacuum  (about  0.0025  mm.),  and  the  electrical  dis- 
charge through  them  produced  a  delicate  glow,  sometimes 
striated,  and  varying  much  in  form  and  color  with  the  degree 
of  exhaustion  and  the  composition  of  the  rarefied  gases  they 
contained. 

Professor  Hittorf  about  1860  discovered  that  the  luminous 
stream  of  discharge  in  a  Geissler  tube  could  be  deflected  by 
a  magnet — a  fact  which  has  an  important  bearing  upon  the 
subsequent  experiments  of  Crookes,  Hertz,  Lenard,  and  Ront- 
gen. 

The  work  of  Geissler  and  Hittorf  was  followed  several  years 
later  by  the  experiments  of  Crookes  with  discharge  tubes  of 
much  higher  vacuum  (about  0.000001  mm.).  With  these 
high  vacuum  tubes  Crookes  discovered  new  phenomena.  He 
found  that  with  sufficiently  high  vacuum  the  luminous  glow 
within  the  tube  disappeared,  and  demonstrated  that  within 

2  17 


18  INTRODUCTION. 

it  there  was  a  rectilinear  radiation  from  the  cathode  which 
was  a  projection  of  particles  of  highly  attenuated  gas  at  exceed- 
ingly high  velocity.  He  called  this  radiation  cathode  rays, 
and  on  account  of  the  peculiar  behavior  of  gas  in  this  exceed- 
ingly rarefied  state  he  conceived  it  to  be  as  different  from 
gas  in  its  properties  as  ordinary  air  or  gas  differs  from  a  liquid. 
He  spoke  of  this  highly  attenuated  condition  as  the  fourth 
or  radiant  state  of  matter.  He  found  that  cathode  rays  were 
intercepted  by  metallic  plates  within  the  vacuum  tube,  that 
their  impact  against  the  glass  wall  of  the  tube  produced  in 
it  a  greenish  phosphorescence  and  fluorescence  and  an  increase 
in  temperature.  He  concentrated  these  rays  at  the  focus  of 
a  concave  cathode,  and  by  this  means  was  able  to  produce 
brilliant  fluorescence  and  a  very  high  temperature  both  at 
the  walls  of  the  tube  and  in  various  substances  within  it.  He 
also  noted  that  the  cathode  rays  were  deflected  by  a  magnet. 

In  1892  Hertz  announced  that  the  cathode  rays  would  pene- 
trate gold  leaf  and  other  thin  sheets  of  metal,  within  the  tube. 
Soon  afterward  Hertz  died,  and  his  experiments  were  continued 
by  his  assistant,  Lenard,  who  found  that  many  of  the  phe- 
nomena of  the  cathode  rays  could  be  observed  outside  of  the 
Crookes  tube.  He  experimented  with  a  vacuum  tube  closed 
at  the  end  opposite  the  cathode  with  a  thin  sheet  of  aluminum, 
and  found  that  the  radiation  which  proceeded  through  or  from 
the  aluminum  wall  of  the  tube  would  pass  through  many  sub- 
stances opaque  to  ordinary  light ;  after  passing  through  such 
substances  it  would  excite  fluorescence  in  crystals  of  barium 
platino-cyanid  and  many  other  salts,  and  that  it  would 
affect  sensitive  photographic  plates  in  much  the  same  manner 
as  ordinary  light. 

Lenard  thought  that  all  of  these  phenomena  were  due  to 
the  cathode  rays  alone,  and,  although  it  can  scarcely  be  doubted 
that  not  only  in  his  experiments  but  in  those  of  Crookes,  Hertz, 
and  other  investigators,  x-rays  were  produced,  they  were  not 
recognized,  and  it  remained  for  another  discoverer  to  bring 
the  results  of  these  long  years  of  patient  scientific  research 
into  practical  application  in  our  daily  life. 

Early  in  November,  1895,  Professor  William  Conrad  Ront- 


INTRODUCTION.  19 

gen,  then  Professor  of  Physics  at  the  Royal  University  of  Wiirz- 
burg,  noticed  that  a  piece  of  paper  coated  with  barium  platino- 
cyanid  fluoresced  brilliantly  in  the  neighborhood  of  a  Crookes 
tube,  even  when  the  tube  was  covered  with  cardboard  which 
intercepted  all  of  the  ordinary  light.  Further  investigation 
proved  that  the  fluorescence  was  caused  by  a  radiation  which 
emanated  from  the  point  of  impact  of  the  cathode  ray  against 
the  glass  wall  of  the  vacuum  tube.  It  was  evident  that  this 
radiation  did  not  produce  the  sensation  of  light,  and  that  it 
passed  readily  through  cardboard,  which  was  opaque  to  ordinary 
light.  Rontgen  also  noticed  that  all  substances  were  trans- 
parent to  this  radiation,  although  in  widely  different  degrees, 
varying  roughly  with  the  density  of  the  material;  that  the 
radiation  was  rectilinear;  that  it  could  not  be  refracted  or 
reflected  to  any  appreciable  extent,  and  that  it  was  not  de- 
flected by  a  magnet.  Hence  it  was  obvious  to  him  that  this 
radiation  was  different  from  the  cathode  rays  of  Crookes, 
Hertz,  and  Lenard.  He  continued  his  observation  both  with 
the  fluorescent  screen  and  the  photographic  plate.  Most  of 
his  early  work  was  of  a  purely  scientific  nature,  and  had  for 
its  object  to  determine,  if  possible,  the  exact  nature  of  the 
new  radiation,  which  he  named  x-rays,  probably  because  of  the 
significance  of  the  letter  x  in  the  mathematical  formulae. 

Using  photographic  plates  wrapped  in  black  paper  to  protect 
them  from  ordinary  light,  Rontgen  obtained  with  the  x-ray 
shadow  pictures  of  metallic  objects  in  a  wooden  box  and  of 
the  bones  of  the  hand.  The  great  possibilities  of  the  x-ray 
in  surgery  were  noted  by  him,  and  in  December,  1895,  he 
communicated  his  discovery  to  the  Physico-Medical  Society  of 
Wiirzburg.  This  communication  was  published  immediately 
all  over  the  civilized  world,  and  hundreds  of  investigators 
repeated  the  experiments  of  Rontgen  and  took  up  at  once 
the  work  of  practical  development  of  his  discovery. 

The  use  of  the  x-ray  in  the  diagnosis  of  fractures,  location 
of  foreign  bodies,  etc.,  at  once  became  general,  and  in  the 
first  few  months  following  its  discovery  experiments  were  made 
to  determine  its  effect  upon  pathogenic  micro-organisms  in 
culture  tubes.  These  experiments  gave  negative  results,  but 


20  INTRODUCTION. 

a  little  later  a  number  of  investigators  observed  valuable  thera- 
peutic effects  when  the  rays  were  directed  upon  living  tissues 
affected  with  tubercular  or  malignant  disease. 

The  generally  accepted  theory  of  the  x-ray  is  that  it  is 
a  disturbance  of  the  ether,  somewhat  of  the  nature  of  ordinary 
light,  but  differing  from  it  in  being  a  series  of  isolated  impulses 
instead  of  a  regular  wave  phenomenon.  Although  we  do  not 
know  just  what  the  x-ray  is,  the  same  thing  may  be  said  of 
gravitation  and  many  other  physical  phenomena  more  familiar 
to  us.  For  the  purpose  of  the  physician  and  surgeon  it  is 
quite  sufficient  to  know  how  to  produce  and  control  the  rays, 
but  it  may  be  well  to  remember  that  they  originate  within 
a  Crookes  tube  at  the  point  of  impact  of  the  cathode  stream 
against  a  solid  body;  that  they  travel  in  straight  lines;  that 
they  cannot  be  refracted  or  reflected  as  ordinary  light;  that, 
therefore,  we  can  only  obtain  shadow  pictures  from  them;  that 
their  range  in  quality  is  much  longer  than  the  range  of  the 
whole  visible  spectrum,  and  that  the  successful  use  of  them 
depends  upon  the  skill  in  those  manipulations  which  secure 
for  us  the  quality  and  intensity  of  the  ray  needed  to  accomplish 
the  desired  results. 

Rontgen's  first  experiments  were  made  with  the  familiar 
pear-shaped  tube  in  which  the  source  of  the  x-ray  is  spread 
over  a  comparatively  large  surface.  Probably  the  most  useful 
single  contribution  that  has  been  made  to  the  practical  side 
of  the  subject  is  the  suggestion  of  Mr.  Herbert  Jackson  of 
using  the  focus  tube  of  Crookes,  thus  reducing  the  source  of 
the  x-rays  to  a  comparatively  small  area,  enabling  the  pro- 
duction of  sharp  shadows,  and  making  it  possible  to  use  a 
much  stronger  exciting  current. 


CHAPTER  I. 
THE  ESSENTIALS  OF  AN  X-RAY  EQUIPMENT. 

THE  two  essentials  of  an  x-ray  equipment  are  Crookes 
tubes,  and  apparatus  capable  of  delivering  electrical  energy 
at  sufficiently-  high  potential  to  produce  discharges  through 
them. 

In  addition  to  the  Crookes  tubes  and  exciting  apparatus 
an  x-ray  outfit  comprises  a  vast  number  of  auxiliary  devices, 
such  as  tube-holders,  switchboards,  controlling  mechanism  for 
coils  and  static  machines,  plate-holders,  fluoroscopes,  operating 
tables,  localizers,  etc.,  which  will  be  described  in  detail  else- 
where. 

The  modifications  of  the  Crookes  tube  which  are  used  in 
practical  x-ray  work  are  made  in  many  forms  and  fitted  with 
many  auxiliary  devices.  They  consist  essentially  of  sealed 
glass  bulbs,  containing  two  or  three  electrodes,  and  exhausted 
to  a  very  high  vacuum.  One  of  the  electrodes  is  made  of 
aluminum,  shaped  like  a  concave  mirror,  and  called  the  cathode 
because  it  is  connected  with  the  negative  terminal  of  the  exciting 
apparatus.  Near  the  focus  of  this  negative  reflector  is  an 
electrode,  which  is  usually  a  flat  disc  of  platinum,  connected 
with  a  terminal  wire  extending  through  the  glass  bulb.  This 
electrode  is  commonly  connected  with  the  positive  wire  from 
the  exciting  apparatus,  and  is  sometimes  called  the  anode. 
However,  the  essential  point  about  it  is  that  it  receives  the 
impact  of  the  cathode  stream,  and  becomes  the  source  of  the 
x-rays.  It  has,  therefore,  been  called  the  target  or  anti-cathode, 
and  it  may  or  may  not  be  the  anode  of  the  tube.  The  various 
forms  of  tubes  and  methods  of  connecting  them  and  regulating 
their  vacua  are  described  in  detail  in  the  next  chapter. 

For  exciting  Crookes  tubes  an  electrical  discharge  of  rather 
high  potential  is  necessary.  The  potential  required  will  vary 
with  the  resistance  of  the  tube,  but  will  always  be  much  higher 

21 


22  ESSENTIALS    OF    AX    X-RAY    EQUIPMENT. 

than  can  be  obtained  directly  from  batteries  or  electric  lighting 
circuits,  and  will  in  practical  work  be  more  than  100,000  volts. 
By  comparison  it  may  be  said  that  the  E.  M.  F.  of  an  ordinary 
storage  cell  is  about  2  volts,  the  incandescent  lighting  circuits 
are  usually  about  110  or  120  volts,  the  current  used  for  operating 
trolley  cars  is  about  500  volts,  and  in  long  distance  power 
transmission  alternating  currents  at  25,000  to  60,000  volts  have 
been  used. 

Electrical  discharges  suitable  for  operating  Crookes  tubes 
may  be  obtained  with  a  static  machine,  high-frequency  coil, 
or  from  the  ordinary  induction  coil.  Excellent  results  have 
been  obtained  with  all  these  appliances,  and  each  has  its  peculiar 
advantages. 

Influence  Machines. — The  influence  machine,  or  static  ma- 
chine as  it  is  commonly  called,  is  an  apparatus  which  converts 
mechanical  energy  directly  into  electricity  at  suitable  potential 
for  use  with  x-ray  tubes.  It  consists  essentially  of  a  number  of 
discs  of  glass  or  mica  arranged  to  revolve  in  an  enclosed  case. 
An  electrical  charge  is  produced  upon  the  surface  of  the  re- 
volving plates,  collected  from  them  by  toothed  collecting  combs, 
and  led  out  through  the  side  of  the  case  to  suitable  terminals. 
These  machines  are  described  more  in  detail  in  Chapter  IV. 

Induction  Coils. — The  induction  coil  is  an  electro-magnetic 
apparatus  which  transforms  the  energy  of  the  ordinary  electrical 
current  derived  from  a  batten',  or  electric  lighting  circuit, 
into  discharges  of  suitable  potential  for  exciting  the  Crookes 
tube.  It  consists  essentially  of  a  core  of  magnetic  material, 
a  primary  winding  consisting  of  a  few  turns  of  coarse  copper 
wire  through  which  the  primary  or  exciting  current  flows, 
and  a  secondary  winding  of  a  great  many  turns  of  very  fine 
wire  in  which  a  high  potential  secondary  discharge  is  generated. 
The  core  is  made  of  a  bundle  of  fine  soft  iron  wires,  or  strips  of 
sheet-iron  laid  up  in  the  form  of  a  cylinder  from  1^  to  3  inches 
in  diameter,  and  from  1£  to  7  feet  long.  Upon  this  core  the 
primary  winding  is  wound  in  from  1  to  4  layers.  Sometimes  the 
ends  of  the  different  layers  are  brought  out  to  separate  terminals 
so  that  they  may  be  connected  together  in  various  combina- 
tions. Outside  of  the  primary  winding  and  very  carefully 


INDUCTION    COILS.  23 

insulated  from  it,  usually  by  a  thick  hard-rubber  tube,  is  the 
secondary  winding  of  very  fine  wire  about  the  size  of  a  small 
sewing  thread.  The  difference  of  potential  in  the  different 
parts  of  this  secondary  winding  is  very  great,  and  it  is  therefore 
necessary  that  great  precaution  be  taken  to  secure  thorough 
insulation  of  the  various  parts  during  its  manufacture.  In 
practice  the  secondary  winding  is  usually  imbedded  in  a  mass 
of  insulating  wax.  The  ends  of  this  secondary  winding  are 
provided  with  well-insulated  terminals  from  which  lead  wires 
are  carried  to  the  Crookes  tube. 

The  action  of  an  induction  coil  is  briefly  as  follows:  An 
electrical  current  from  a  battery,  or  other  sources,  is  passed 
through  the  primary  winding,  causing  the  core  to  become 
magnetic.  Thus,  a  certain  amount  of  the  energy  of  the  exciting 
current  is  stored  up  in  the  core.  When  the  primary  current 
is  interrupted,  the  core  very  suddenly  loses  its  magnetism  and 
the  energy  stored  up  in  it  reappears  as  an  electrical  discharge 
of  very  short  duration  and  very  high  potential  in  the  secondary 
winding.  In  practical  x-ray  work  this  magnetization  and  de- 
magnetization of  the  core  are  made  to  take  place  very  rapidly — 
from  5  to  200  times  a  second.  This  is  accomplished  by  various 
devices  for  rapidly  starting  and  stopping  the  current  through 
the  primary  winding  of  the  coil.  Such  devices  are  known  as 
interrupters.  They  have  been  made  in  many  forms;  some  of 
the  best-known  types  are  described  in  Chapter  III. 

The  degree  of  magnetization  of  the  core  increases  at  a  com- 
paratively slow  rate,  but  its  demagnetization  is  very  sudden 
at  the  break  of  the  primary  circuit.  The  secondary  discharge 
produced  therefore  at  the  opening  of  the  primary  circuit  is 
of  exceedingly  short  duration,  probably  not  more  than  one- 
five-hundredth  part  of  a  second.  In  a  coil  operating  at  50 
interruptions  a  second  there  would  be  in  one  second  50  secondary 
discharges  of  exceedingly  short  duration  followed  by  intervals 
of  rest  about  ten  or  twenty  times  as  long  as  the  periods  of  the 
discharge.  Thus  it  will  be  seen  that  there  is  a  difference  between 
the  discharge  obtained  from  an  induction  coil  and  that  from 
a  static  machine,  which  when  connected  directly  to  the  Crookes 
tube  yields  practically  an  even  steady  flow  of  current,  much 


24  ESSENTIALS    OF   AN    X-RAY    EQUIPMENT. 

weaker  but  occupying  the  whole  period.  However,  Crookes 
tubes  excited  either  with  a  static  machine  or  coil  produce 
practically  the  same  effects  upon  the  photographic  plate,  upon 
the  tissues  of  the  body,  and,  so  far  as  the  eye  is  concerned, 
upon  the  fluorescent  screen. 

High-frequency  Coils. — The  high-frequency  coils  of  Tesla, 
Kinraide,  and  others  operate  in  a  somewhat  similar  manner 
to  the  ordinary  induction  coil,  but  they  are  excited  not  by 
an  ordinary  electric  current  interrupted  suddenly  a  few  times 
a  second,  but  by  a  series  of  very  rapidly  oscillating  currents 
of  perhaps  several  hundred  thousand  ,  alternations  a  second. 
Owing  to  the  exceeding  rapidhy  of  the  oscillations  of  the  pri- 
mary current,  these  high-frequency  coils  can  be  made  to  give 
high-potential  discharges  with  a  comparatively  small  number 
of  turns  of  fine  wire  in  the  secondary  winding.  They  produce 
brilliant  x-ray  effects,  but  they  give  discharges  which  alternate 
in  direction,  and  which  are,  therefore,  not  so  well  adapted 
for  practical  x-ray  work  as  those  obtained  from  a  static  machine 
or  ordinary  induction  coil.  The  alternations  of  the  discharge 
cause  much  wear  on  the  Crookes  tubes,  and  they  produce 
sources  of  x-rays  at  other  points  than  the  target,  thus  impairing 
the  definition  of  the  tube.  For  radiographic  purposes,  there- 
fore, the  high-frequency  outfits  are  not  very  satisfactory, 
though  for  therapeutic  work  they  answer  very  well,  except 
for  the  rapid  destruction  of  the  tubes. 

Available  Sources  of  Electrical  Energy. — The  electrical  energy 
necessary  for  operating  x-ray  apparatus  may  be  obtained 
either  from  batteries  or  electric  lighting  or  power  circuits. 

Batteries. — All  forms  of  batteries  are  objectionable,  because 
of  the  corrosive  solutions  they  contain,  because  they  deteriorate 
more  or  less  rapidly,  and  because  of  the  annoyance  and  trouble 
due  to  the  corrosion  of  contacts,  breakage,  etc. 

An  electrical  battery  consists  essentially  of  two  electrodes 
of  dissimilar  materials  immersed  in  a  conducting  solution  of 
such  a  nature  that  chemical  changes  take  place  when  the  two 
electrodes  are  so  connected  that  an  electrical  current  may 
flow  from  one  to  the  other.  The  energy  of  the  current  pro- 
duced is  derived  from  these  chemical  changes.  In  nearly  all 


STORAGE    BATTERIES.  25 

primary  batteries  one  of  the  electrodes  is  composed  of  zinc, 
and  during  the  action  of  the  battery  this  zinc  electrode,  or  ele- 
ment, enters  into  chemical  combination  with  the  solution, 
and  is  worn  away  in  proportion  to  the  amount  of  current  passed 
through  it.  It  is  therefore  necessary  after  a  time  to  renew 
both  the  zinc  and  the  solution.  On  account  of  this  troublesome 
and  expensive  process  primary  batteries  are  not  recommended 
when  other  sources  of  electrical  current  are  available. 

There  are  several  forms  of  primary  batteries  on  the  market 
which  will  deliver  strong  enough  currents  for  operating  in- 
duction coils.  Of  these  may  be  mentioned  the  bichromate 
cell,  having  a  voltage  of  1.8,  the  Edison-Lalande  with  a  voltage 
of  0.7,  and  the  Gordon-Burnham  with  a  voltage  of  about  1.5 
a  cell. 

Storage  Batteries. — In  the  storage  battery  the  two  dissimilar 
electrodes  consist  of  two  dissimilar  oxids  of  lead  which  are 
held  upon  plates  of  metallic  lead  which  serve  as  conducting 
supports  for  them.  These  are  immersed  in  a  solution  of  dilute 
sulphuric  acid.  In  a  storage  battery  the  chemical  changes 
which  go  on  during  the  passage  of  the  current  are  such  that 
the  original  condition  of  the  electrodes  or  elements  may  be 
restored  by  forcing  a  current  through  the  cell  in  an  opposite 
direction.  It  is  therefore  a  much  simpler  matter  to  recharge 
a  storage  battery  than  a  primary  battery,  because  the  elements 
do  not  have  to  be  disturbed  or  renewed. 

Lead  storage  batteries  have  an  E.  M.  F.  of  about  2  volts 
and,  since  from  6  to  20  volts  are  required  to  operate  an  induc- 
tion coil,  from  3  to  10  storage  cells  will  be  needed.  Some 
arrangement  must  be  provided  for  charging  these  cells.  They 
may  be  transported  to  a  charging  station,  or  if  they  are  to 
be  used  for  only  a  few  minutes  at  a  time  at  intervals  of  two 
to  three  days  they  may  be  charged  by  a  primary  battery, 
which  does  not  deliver  its  energy  fast  enough  for  operating 
a  coil  directly,  but  which  will  store  up  in  a  day  or  two  in  a 
storage  battery  sufficient  energy  for  operating  a  coil  for  a 
few  minutes.  The  most  suitable  form  of  battery  for  this 
purpose  is  the  ordinary  gravity  cell,  which  has  been  used 
extensively  for  telegraph  work.  These  gravity  cells  will  remain 


26  ESSENTIALS    OF   AX   X-RAY    EQUIPMENT. 

in  operation  for  several  months  on  one  charge,  and  may  be 
connected  permanently  with  the  storage  battery.  About  3  or 
4  cells  of  the  gravity  battery  will  be  required  for  each  storage 
cell.  When  a  storage  battery  is  allowed  to  remain  discharged 
for  some  time,  abnormal  chemical  processes  go  on,  which 
seriously  impair  its  usefulness.  They  should,  therefore,  not  be 
allowed  to  become  fully  discharged,  and  should  be  kept  as  nearly 
as  possible  fully  charged  all  the  time. 

Electric  Lighting  and  Power  Circuits. — These  circuits  may 
be  divided  into  two  classes — direct  current  and  alternating 
current.  The  direct  current  lighting  circuits  furnish  steady 
undirectional  currents  at  a  voltage  of  about  110  or  120  volts. 
Most  of  the  railway  and  some  power  circuits  furnish  direct  cur- 
rent at  500  volts. 

The  alternating  current  reverses  its  direction  usually  about 
60  times  a  second,  and  it  is  distributed  for  electric  lighting 
at  about  the  same  voltage  as  the  direct  current.  It  constantly 
changes  its  direction,  producing  entirely  new  phenomena  and 
necessitating  modifications  for  employing  it  in  operating  x-ray 
coils.  For  operating  induction  coils  the  direct  current  circuit 
of  110  or  120  volts  is  the  best  source  of  supply  that  may  be 
obtained. 

If  the  static  machine  is  used,  it  may  be  operated  by  a  motor 
driven  from  any  one  of  these  circuits,  and  it  therefore  makes 
very  little  difference  what  kind  of  a  circuit  is  available,  except 
that  motors  for  the  alternating  current  do  not  permit  of  speed 
regulation,  but  run  at  a  constant  speed,  while  direct  current 
motors  may  be  provided  with  means  for  speed  control. 

Several  means  have  been  devised  for  operating  coils  from 
an  alternating  current  circuit.  One  method  is  to  employ  a 
motor  generator  which  receives  its  power  from  the  alternating 
current  circuit,  and  delivers  a  direct  current  at  from  50  to 
100  volts. 

To  operate  a  coil  directly  from  the  alternating  current  circuit 
a  cheaper,  although  not  quite  so  satisfactory,  method  is  to 
employ  some  special  auxiliary  device  which  allows  the  current 
to  flow  only  in  one  direction,  or  which  interrupts  it  only  when 


FLUORESCENT  SCREENS  AND  PHOTOGRAPHIC  PLATES.    27 

the  current  is  flowing  in  one  direction.  For  this  purpose  a 
Wehnelt  interrupter  may  be  used. 

Fluorescent  Screens  and  Photographic  Plates. — The  x-ray 
produces  no  sensation  of  light  upon  the  eyes,  therefore  in  order 
to  employ  it  in  diagnosis  we  must  use  intermediate  means  for 
making  its  effects  visible.  We  have  seen  that  photographic 
plates  are  affected  by  the  x-rays  in  much  the  same  way  as  by 
ordinary  light,  and  that  certain  crystals  are  caused  by  it  to 
fluoresce  or  give  off  visible  light.  We  may  interpose  the  object 
which  we  wish  to  examine  between  the  photographic  plate 
and  the  source  of  x-ray,  and  upon  development  of  the  plate 
a  shadow-picture  of  the  object  will  appear.  In  a  similar  manner 
we  may  obtain  shadow-pictures  on  a  piece  of  cardboard  coated 
with  a  fluorescent  material. 

Photographic  plates  are  caused  to  fluoresce  by  the  x-ray, 
but  it  has  not  yet  been  determined  whether  the  photochemical 
action  is  a  secondary  one  due  to  this  fluorescence,  or  is  pro- 
duced directly  by  the  x-ray.  In  most  fluorescent  substances 
there  is  also  a  phosphorescence  which  persists  after  the  x-ray 
has  ceased.  The  substance  which  fluoresces  most  strongly  and 
is  best  adapted  for  practical  use,  is  the  double  cyanid  of  barium 
and  platinum.  This  gives  a  bright  greenish  fluorescence  with 
comparatively  little  phosphorescence.  Tungstate  of  calcium, 
which  was  first  brought  into  prominence  by  Edison,  fluoresces 
and  phosphoresces  with  a  bluish  light,  which,  although  it  does 
not  affect  the  retina  so  strongly  as  the  green  light  from  the 
barium  salt,  has  a  much  more  powerful  effect  upon  the  photo- 
graphic film  or  plate. 


CHAPTER  II. 
X-RAY  TUBES, 

IT  is  sometimes  supposed  that  a  Crookes  tube  is  a  standard 
article  of  manufacture,  and  that  like  an  incandescent  lamp  it 
will  have  a  definite  number  of  hours  of  life;  that  it  is  adapted 
for  a  certain  spark-length  as  a  lamp  is  adapted  for  a  certain 
voltage,  and  that  in  order  to  operate  it  all  that  is  necessary 
is  to  turn  on  the  current.  A  very  little  experience  will  suffice 
to  prove  the  fallacy  of  such  a  supposition. 

It  is  true  that  many  tubes  are  rated  for  a  certain  spark 
length.  These  ratings  are  very  indefinite,  and  may  refer  to 
the  degree  of  exhaustion  or  to  the  size  of  the  bulb.  The  degree 
of  exhaustion  is  a  constantly  variable  factor,  and  the  size  of 
the  bulb  is  always  an  unimportant  one.  Consequently,  these 
ratings  are  of  little  use,  except  that  to  a  certain  extent  they 
may  indicate  the  amount  of  material  in  the  electrodes  and 
therefore  give  an  idea  of  the  strength  of  the  exciting  current 
that  may  be  used  with  them.  A  tube  marked  15  cm.  may 
be  operated  perfectly  with  a  coil  capable  of  giving  a  spark 
100  cm.  long,  but,  of  course,  such  a  tube  will  not  withstand 
the  heaviest  discharges  that  may  be  produced  with  such  a 
coil.  A  tube  marked  60  cm.  may  be  operated  very  satisfactorily 
with  a  coil  of  20  cm.  maximum  spark  length,  but  a  20-cm. 
coil  will  probably  not  furnish  enough  energy  to  produce  the 
maximum  excitation  which  the  tube  will  withstand.  Tubes 
marked  40  to  60  cm.  are  usually  strongly  made,  and  have 
heavy  electrodes  such  as  are  suitable  for  use  with  exciting 
apparatus  giving  heavy  discharges.  The  tubes  marked  15  to  30 
cm.  usually  have  small  bulbs  and  lighter  electrodes,  which 
will  not  withstand  the  heavy  discharges  of  a  large  induction 
coil,  but  will  operate  very  satisfactorily  with  a  static  machine 
or  a  small  coil.  The  size  of  the  bulb  has  little  to  do  with  the 
operation  of  a  tube,  but  it  will  be  obvious  that  the  vacuum 

28 


GENERAL    PROPERTIES   AND    DEFINITION.  29 

of  a  large  tube  will  not  be  so  susceptible  to  change  from  the 
small  amount  of  occluded  gas  as  a  tube  of  smaller  size. 

General  Properties  of  Tubes. — The  rays  produced  by  different 
tubes  vary  widely  in  many  respects.  Some  tubes  produce  rays 
of  exceedingly  high  penetration,  and  rays  from  other  tubes 
may  have  so  little  penetration  that  the  shadow  of  the  flesh 
of  the  hand  is  perfectly  black,  and  the  bones  cannot  be  seen. 
Some  tubes  will  produce  sharp  shadows  on  the  fluorescent 
screen,  and  others  give  blurred  images  of  any  object  held  a 
short  distance  away  from  the  screen.  Some  tubes  operate 
steadily  with  very  little  change  in  the  quality  of  the  rays, 
while  others  will  fluctuate  rapidly  from  time  to  time  during  use. 
There  are  so  many  factors  which  vary  the  properties  of  a  Crookes 
tube  that  it  is  almost  impossible  to  make  two  exactly  alike. 
Two  tubes  which  are  very  nearly  alike  when  new  may  after 
a  few  minutes'  use  be  entirely  different  in  character. 

Definition. — For  diagnostic  work  it  is  important  to  employ 
tubes  which  will  produce  sharp,  distinct  shadows  of  the  object 
under  examination.  This  condition  will  be  obtained  only  in 
a  tube  in  which  the  source  of  x-rays  is  at  a  comparatively 
small  point  on  the  surface  of  the  target.  The  smaller  this  focus 
point  of  the  cathode  stream,  the  sharper  will  be  the  shadows. 
It  must  be  remembered,  however,  that  if  this  focus  is  exceed- 
ingly small,  the  intensity  of  the  heat  produced  at  the  point 
will  be  correspondingly  increased,  therefore  in  a  tube  of  exceed- 
ingly fine  focus  there  is  liability  of  melting  a  hole  through 
the  target  at  the  focus  point. 

If  the  focus  point  is  large,  the  shadows  will  have  penumbra 
and  all  the  fine  detail  will  be  lost.  Such  a  tube,  however, 
may  be  used  safely  with  very  strong  currents,  because  the 
impact  of  the  cathode  stream  is  spread  over  a  larger  surface 
and  is  not  so  intense  at  any  one  point.  For  therapeutic  pur- 
poses the  matter  of  focus  is  unimportant.  It  is  therefore  well 
to  use  for  this  work  tubes  whose  definition  is  not  sufficiently 
good  for  diagnostic  work. 

For  use  in  radiography  and  fluoroscopy  tubes  having  focus 
points  of  not  less  than  -^  or  more  than  -J  of  an  inch  in  diameter 
will  usually  fulfil  the  requirements  for  definition  and  life. 


30  X-RAY   TUBES. 

Good  definition  in  a  tube  is  secured  by  having  the  cathode 
accurately  ground,  of  proper  curvature,  and  the  target  placed 
at  the  proper  distance  from  the  cathode.  Owing  to  the  mutual 
repulsion  of  the  particles  of  the  cathode  stream  they  do  not 
come  to  a  focus  at  the  distance  of  the  radius  of  curvature  of 
the  cathode,  but  at  a  point  beyond  it,  the  distance  depending 
somewhat  upon  the  degree  of  exhaustion.  In  practice  the 
distance  between  the  target  and  the  cathode  is  made  not  less 
than  twice  the  radius  of  curvature,  and  in  a  well-designed 
tube  the  change  in  the  position  of  the  focus  with  the  different 
degrees  of  exhaustion  is  so  little  that  the  definition  is  not 
seriously  affected  throughout  the  whole  useful  working  range 
of  vacuum.  In  every  x-ray  tube  there  is  a  certain  amount 
of  bombardment  at  other  points  than  the  target,  and  this 
gives  rise  to  weak  rays  which  are  termed  by  the  French  operators 
parasitic  rays.  In  certain  tubes  these  may  be  strong  enough 
to  seriously  interfere  with  the  definition,  but  in  a  good  tube 
these  parasitic  rays  will  be  so  much  weaker  than  the  rays 
originating  at  the  target  that  they  need  not  be  considered. 

Penetration. — The  penetration  of  the  rays  derived  from  a 
tube  depends  upon  a  number  of  factors,  but  bears  a  close 
relation  to  the  resistance  which  the  tube  offers  to  the  exciting 
current.  The  resistance  of  the  tube  depends  mainly  upon  its 
vacuum,  but  also  upon  the  size  of  the  electrodes,  the  distance 
separating  them,  and  upon  the  amount  of  occluded  gas  in 
the  electrodes.  The  character  of  the  discharge  used  for  exciting 
a  Crookes  tube  may  have  much  to  do  with  the  resistance  which 
it  offers  and  with  the  penetration  of  the  rays  obtained  from 
it.  For  example,  the  discharge  of  a  static  machine  may  be 
so  altered  by  a  series  of  spark  gaps  in  circuit  with  the  tube 
that  the  discharge  passes  with  difficulty  through  a  tube  of 
such  low  vacuum  that  without  the  spark  gaps  it  would  not 
possess  sufficient  resistance  to  cause  the  production  of  x-rays. 

It  is,  of  course,  important  to  be  able  to  control  the  penetration 
of  the  rays,  and  to  regulate  it  to  suit  the  different  conditions 
of  work.  In  order  to  accomplish  this  we  must  be  able  to 
regulate  the  resistance  which  the  tube  offers  to  the  passage 


PRODUCTION    AND    DISSIPATION    OF    HEAT    IN   TUBES.  31 

of  the  exciting  current.*  The  usual  method  of  accomplishing 
this  is  by  varying  the  degree  of  the  vacuum,  and  a  number 
of  devices  have  been  designed  for  this  purpose. 

As  has  been  mentioned  before,  the  degree  of  the  vacuum 
of  the  tube  is  unstable  and  changes  with  use;  the  tendency 
of  most  tubes  is  to  become  higher  in  vacuum  after  continued 
use,  until  finally  they  become  so  high  that  re-exhaustion  is  neces- 
sary. A  certain  amount  of  gas  is  occluded  on  the  inner  surface 
of  the  bulb  and  especially  upon  the  platinum  target.  When 
the  tube  is  used,  its  temperature  rises  somewhat,  and  some 
of  this  occluded  gas  is  driven  off,  thus  temporarily  lowering 
the  vacuum,  which  rises  again  when  the  tube  is  cooled.  In 
some  tubes,  however,  there  may  be  an  exceedingly  small  leak 
through  which  air  enters  and  very  gradually  reduces  the  vacuum. 

From  these  facts  it  will  be  deduced  that  a  satisfactory  and 
convenient  means  for  controlling  the  vacuum  of  an  x-ray  tube 
is  very  desirable. 

Devices  for  regulating  the  vacuum  were  among  the  first 
developments  of  Crookes  tubes  for  x-ray  work,  and  in  the 
following  pages  are  shown  a  number  of  tubes  with  ingenious 
regulating  apparatus  of  various  types.  However,  no  regulating 
device  has  yet  been  produced  which  gives  as  good  control 
of  the  vacuum  as  may  be  desired,  and  many  operators  prefer 
to  use  plain  tubes  without  auxiliary  vacuum  regulators. 

Production  and  Dissipation  of  Heat  in  Tubes. — The  impact 
of  the  cathode  stream  upon  the  focus  point  of  the  target  pro- 
duces heat  as  well  as  x-rays,  and  with  the  powerful  exciting 
apparatus  which  is  necessary  for  rapid  radiographic  work  the 
amount  of  heat  evolved  will  be  great  enough  to  melt  a  hole 
through  the  ordinary  platinum  target.  For  this  work  it  is 
therefore  necessary  to  employ  tubes  with  targets  which  are 
capable  of  withstanding  a  great  rise  of  temperature,  or  of 
dissipating  a  considerable  amount  of  heat.  One  method  of 
accomplishing  this  is  to  make  the  target  of  a  considerable 

*  The  word  resistance  as  applied  to  x-ray  tubes  is  not  a  very  good  one.  Ob- 
viously the  passage  of  an  electrical  discharge  through  a  Crookes  tube  is  essentially 
different  from  the  flow  of  an  electric  current  through  a  metallic  conductor,  and 
the  obstruction  which  the  tube  offers  to  the  discharge  differs  from  the  electrical 
resistance  of  a  metallic  conductor. 


32  X-RAY   TUBES. 

mass  of  metal  having  large  thermal  capacity.  Some  makers 
have  employed  large  targets  of  copper  or  some  alloy,  sometimes 
faced  with  a  thin  sheet  of  platinum,  and  occasionally  blackened 
to  facilitate  radiation  of  heat  from  them.  The  difficulties  of 
these  cheap  metals  are  that  they  cannot  be  heated  to  a  very 
high  temperature  without  giving  off  so  much  vapor  that  the 
vacuum  of  the  tube  is  reduced  to  such  a  point  as  to  render 
it  useless  for  the  time  being.  With  very  short  exposures, 
however,  the  large  thermal  capacity  of  the  mass  of  metal, 
and  its  high  conductivity  for  heat  prevent  a  great  rise  of  tem- 
perature, and  they  work  very  well.  Platinum  does  not  vaporize 
in  the  tube,  and  a  target  having  a  large  mass  of  this  metal 
may  therefore  be  heated  to  a  very  high  temperature  without 
seriously  impairing  the  vacuum.  The  high  price  of  platinum 
makes  such  tubes  very  expensive,  but  when  it  is  considered 
that  the  platinum  is  not  destroyed,  and  that  the  same  target 
may  be  used  for  making  a  new  tube,  this  matter  is  not  so  im- 
portant. The  author  has  tubes  with  targets  containing  from 
$25.00  to  $50.00  worth  of  platinum  which  have  been  re-made 
several  times  at  comparatively  small  expense.  Iridium  and 
osmium  are  harder  and  will  withstand  higher  temperatures 
than  platinum,  but  these  metals  are  rarer  and  more  expensive 
than  platinum.  However,  a  heavy  platinum  target  faced  with 
a  small  piece  of  iridium  at  the  focus  point  of  the  cathode  stream 
makes  a  very  satisfactory  arrangement,  and  its  expense  is 
not  prohibitive.  These  metals,  however,  give  off  gases  in  an 
exceedingly  irregular  manner,  and  it  is  therefore  necessary 
with  such  tubes  to  use  a  regulating  device  of  wide  range  and 
great  efficiency. 

Cooling  the  target  by  a  stream  of  water  or  oil  in  contact 
with  it  has  been  attempted  by  a  number  of  makers.  One  of 
the  first  of  these  tubes  was  that  devised  by  Dr.  Rollins  in 
which  the  target  consisted  of  a  long  platinum  tube  sealed  in 
the  bulb,  and  provided  with  an  inlet  and  outlet  through  which 
the  cooling  liquid  could  be  circulated.  These  tubes  were  very 
expensive  on  account  of  the  large  amount  of  platinum  necessary. 

Some  makers  have  placed  in  contact  with  the  target  a  glass 
chamber  through  which  the  cooling  liquid  is  circulated.  This 


OPERATION    OF   THE    TUBE.  33 

construction  obviates  the  difficulties  of  sealing  the  large  plati- 
num tube  in  the  glass,  but  in  these  tubes  the  heat  must  be 
conducted  through  the  glass  before  it  can  be  absorbed  by 
the  liquid.  Glass  is  such  a  poor  conductor  of  heat  that  in 
practice  the  target  of  such  a  tube  may  be  dangerously  heated 
before  the  liquid  within  the  cooling  chamber  shows  an  appre- 
ciable rise  in  temperature. 

Miiller,  of  Hamburg,  has  succeeded  in  making  a  tube  in 
which  the  target  consists  of  a  cap  of  platinum  sealed  in  the 
end  of  a  glass  tube  which  projects  within  the  bulb,  and  which 
outside  of  the  bulb  is  enlarged  into  a  little  bottle  for  containing 
the  cooling  liquid.  This  construction,  like  that  of  Rollins, 
permits  the  liquid  to  come  in  direct  contact  with  the  metal 
of  the  target.  Of  the  water-cooled  tubes  this  is  unquestionably 
the  most  effective.  The  high  specific  heat  and  the  large  mass 
of  the  liquid  prevent  it  from  attaining  a  high  temperature 
during  any  ordinary  radiographic  exposure,  but  even  in  such 
a  tube  with  the  water  in  direct  contact  with  one  side  of  the 
thin  platinum  target  the  discharge  from  a  powerful  induction 
coil  may  cause  the  face  of  it  to  become  white  hot. 

For  use  with  static  machines  and  induction  coils  of  small 
size,  such  as  are  used  for  ordinary  fluoroscopic  work  and  for 
therapeutic  purposes,  such  elaborate  cooling  devices  are  quite 
unnecessary.  For  the  most  rapid  exposures  in  radiographic  work 
it  is  necessary  to  use  very  powerful  discharges,  and  no  tube 
has  yet  been  produced  which  will  withstand  as  much  current 
as  it  is  desired  to  use.  The  most  effective  tubes  for  this  work 
are  the  water-cooled  tubes  and  those  with  heavy  targets. 

Operation  of  the  Tube. — Success  in  radiographic  work,  or,  in 
fact,  in  any  kind  of  x-ray  work,  depends  largely  upon  the  proper 
manipulation  of  the  tube.  This  is  the  most  difficult  part  of 
the  subject  to  acquire,  and  proficiency  in  it  can  be  obtained 
only  by  experience,  and  probably  at  the  cost  of  a  good  many 
ruined  tubes. 

X-ray  tubes  are  exceedingly  fragile,  and  easily  damaged. 
It  is  therefore  necessary  to  observe  certain  precautions  in 
using  them  in  order  to  prevent  puncture,  or  breakage,  or  black- 
ening the  bulb  and  seriously  impairing  the  vacuum. 

3 


34  X-RAY   TUBES. 

Temperature. — Tubes  should  not  be  used  when  they  are  very 
much  cooler  than  the  temperature  of  the  room,  as  will  be 
the  case  when  an  expressman  has  delivered  one  on  a  winter's 
day.  It  is  a  good  plan  to  warm  the  tube  gently  over  a  radiator 
until  the  temperature  reaches  60°  to  70°  F. 

Clamping  the  Tube. — The  various  holders  for  supporting  the 
tube  in  operation  are  described  in  another  chapter,  but  it 
is  perhaps  advisable  to  repeat  cautions  against  clamping  the 
tube  so  strongly  as  to  put  the  glass  upon  a  strain,  and  thus 
render  it  liable  to  crack  or  puncture,  or,  on  the  other  hand, 
clamp  it  so  loosely  that  a  little  pull  upon  the  connecting  wire 
will  detach  it,  and  let  it  fall  and  break.  The  clamping  part 
of  the  tube-holder  should  be  carefully  examined  to  see  that 
it  fits  the  tube.  It  should  be  lined  with  some  yielding  sub- 
stance such  as  cork  or  felt  to  prevent  undue  strain. 

Most  of  the  tubes  are  provided  with  a  small  projecting  tip, 
sometimes  covered  with  a  piece  of  soft-rubber  tubing,  for 
the  tube  clamp,  but  these  tips  are  usually  too  small  to  give 
a  good  firm  grip  on  the  tube,  and  with  a  proper  clamp  it  is 
better  to  support  the  tube  as  near  the  bulb  as  possible.  The 
most  convenient  point  is  around  the  neck  which  carries  either 
the  cathode  or  anode,  but  usually  the  cathode. 

Connecting  Wires. — The  connecting  wires  should  be  as  small 
and  flexible  as  the  requirements  for  mechanical  strength  will 
permit.  A  copper  wire  as  large  as  a  small  sewing  thread  has 
ample  carrying  capacity  for  the  strongest  currents  which  will 
be  used  in  exciting  the  tube.  A  thick,  heavy  wire  is  awkward 
to  manage,  and  with  it  the  platinum  terminal  wires  of  the 
tube  are  very  liable  to  be  broken  off.  For  use  with  an  induction 
coil  a  very  convenient  lead  wire  for  the  tube  is  the  ordinary 
bare  tinsel  cord,  to  the  end  of  which  is  attached  a  short  piece 
of  copper  wire,  about  No.  24  B.  &  S.,  which  may  be  bent  into 
a  hook  for  attachment  to  the  terminal  of  the  tube.  With 
this  tinsel  cord  it  is  very  convenient  to  have  two  spools  upon 
which  it  may  be  wound.  These  spools  make  it  easy  to  adjust 
the  length  of  the  cords  so  that  they  do  not  lie  across  the  bulb, 
where  they  would  probably  produce  a  puncture,  or  across 
the  secondary  of  the  coil,  where  a  spark  is  liable  to  pass  and 


CONNECTING    WIRES.  35 

injure  the  insulation.  The  lead  wires  should  be  separated  from 
each  other  at  every  point  by  a  distance  of  not  less  than  six 
or  eight  inches,  and  they  should  not  be  approached  nearer 
than  four  inches  to  the  body  of  the  patients  or  to  metallic 
objects,  such  as  gas  pipes  or  metal  parts  of  the  apparatus, 
for  the  reason  that  the  spark  might  pass  and  give  a  shock 
to  the  patient,  or,  by  grounding,  unnecessarily  strain  the  insula- 
tion of  the  coil. 

With  a  static  machine  there  is  a  tendency  for  brush  dis- 
charges to  form  from  any  exposed  points  connected  with  the 
terminals.  Bare  tinsel  cord  cannot  therefore  be  used,  and  it 
is  necessary  to  heavily  insulate  the  lead  wires.  In  order  to 
prevent  these  brush  discharges,  and  at  the  same  time  secure 
maximum  flexibility  I  have  used  a  very  small  conductor  made 
up  of  seven  No.  33  copper  wires  passed  through  an  ordinary 
soft  rubber  tube  about  one-fourth  of  an  inch  in  diameter. 

Before  connecting  the  tube  it  is  well  to  ascertain  the  polarity 
of  the  terminals  of  the  exciting  apparatus.  The  negative  ter- 
minal of  the  exciting  apparatus  should  be  connected  with  the 
cathode, — which  is  the  cup-shaped  aluminum  electrode, — and 
the  positive  terminal  with  the  target  or  anode.  It  is  advisable 
to  have  the  exciting  apparatus  provided  with  an  arrangement 
which  enables  a  spark  gap  to  be  put  in  series  with  the  lead 
wires,  and  which  allows  the  length  of  this  spark  to  be  adjusted 
while  the  tube  is  in  operation.  The  object  of  the  gap  is  two- 
fold— a  certain  amount  of  regulation  of  the  quality  of  the 
rays  may  be  obtained  with  it,  and  with  the  coil  it  prevents, 
to  a  certain  extent,  the  inverse  discharge,  produced  at  the 
make  of  the  primary  current,  from  passing  into  the  tube  and 
blackening  it  or  interfering  with  its  operation. 

It  is  always  advisable  to  start  the  tube  with  a  weak  exciting; 
current  and  increase  the  strength  gradually  until  the  desired 
effect  is  obtained.  This  is  a  precaution  which  will  often  prevent 
puncturing  the  tube. 

If  the  tube  is  of  moderate  vacuum,  such  that  the  terminals 
of  the  exciting  apparatus  must  be  approached  within  three 
inches  before  a  spark  passes  between  them,  in  preference  to 
passing  through  the  tube,  the  bulb  will  light  up  with  a  yellowish- 


36  X-RAY   TUBES. 

green  fluorescence,  the  shade  depending  largely  upon  the 
material  of  the  glass  and  the  length  of  time  the  tube  has  been 
used.  This  fluorescence  will  be  confined  almost  entirely  to 
the  hemisphere  on  one  side  of  the  plane  of  the  target,  and 
its  intensity  will  vary  with  the  strength  of  the  exciting  current. 
In  the  hemisphere  back  of  the  target  there  will  be  a  slight 
trace  of  fluorescence,  and  perhaps  a  trace  of  a  delicate  bluish 
glow  within  the  bulb  back  of  the  anode.  Such  a  tube  is  oper- 
ating properly,  and  the  strength  of  the  exciting  current  may 
be  gradually  increased  until  the  desired  intensity  of  the  rays 
is  obtained,  or  until  the  target  begins  to  show  signs  of  undue 
heating.  The  appearance  of  a  tube  operating  in  this  way  is 
shown  very  well  in  figure  1. 

If  by  mistake  a  tube  has  been  connected  with  the  wrong 
poles  of  the  exciting  apparatus,  the  appearance  is  quite  dif- 
ferent. There  will  be  an  irregular  illumination  at  different 
parts  of  the  bulb,  and  bright  rings  will  probably  appear  on 
the  glass.  The  appearance  of  a  tube  connected  in  this  way 
is  very  well  shown  in  figure  2.  If  a  tube  is  connected  in  this 
way,  the  direction  of  the  exciting  current  through  the  tube 
should  be  reversed.  Running  a  tube  in  the  reverse  direction 
tends  to  blacken  the  bulb  with  a  fine  deposit  of  metal  thrown 
off  from  the  electrodes,  and  make  it  subject  to  very  sudden 
and  erratic  fluctuations  in  resistance. 

If  the  resistance  of  the  tube  is  so  low  that  the  discharge 
rods  of  the  exciting  apparatus  may  be  approached  within  an 
inch  of  each  other  before  a  spark  passes,  there  will  be  a  bluish 
glow  within  the  bulb,  and  sometimes  a  cone-shaped  glow  may 
be  detected  extending  between  the  faces  of  the  cathode  and 
target.  The  penetration  of  a  tube  operating  in  this  manner 
is  too  low  for  practical  x-ray  work,  and  unless  it  is  provided 
with  means  for  increasing  its  resistance  or  for  increasing  its 
penetration  by  the  spark  gap  methods,  it  will  have  to  be  sent 
to  the  makers  for  re-exhaustion.  The  appearance  of  a  low 
vacuum  tube  is  shown  very  well  in  figure  3. 

It  may  be  that  when  the  exciting  current  is  turned  on.  the 
resistance  of  the  tube  is  so  high  that  it  does  not  light  up  steadily, 
but  flashes  faintly,  and  sparks  have  a  tendency  to  pass  around 


FIG.  1.— X-RAY  TUBE  OPERATING  PROPERLY. 


FIG.  2. — APPEARANCE  OF  X-RAY  TUBE  WITH  CURRENT  REVERSED. 


PUNCTURES.  37 

f^n  the  outside  of  the  glass.  This  is  a  signal  to  turn  off  the 
current  quickly,  for  in  this  condition  the  tube  is  very  likely 
to  be  punctured.  It  is  well  to  have  the  discharge  rods  of  the 
exciting  apparatus  separated  not  more  than  six  or  eight  inches 
in  order  that  the  discharge  may  pass  between  them  in  preference 
to  running  around  the  wall  of  the  tube  where  it  is  liable  to 
do  damage. 

If  the  tube  is  provided  with  one  of  the  regulating  devices, 
its  vacuum  will  be  readily  lowered.  If  a  tube  has  no  vacuum 
regulator  it  may  be  lowered  by  heating  it  gradually  in  the 
flame  of  an  alcohol  lamp.  A  certain  amount  of  gas  may  be 
liberated  in  this  way  from  any  part  of  the  walls  of  the  tube. 
Unless  it  is  very  old,  sufficient  gas  may  be  driven  off  so  that 
the  discharge  will  pass  through  the  tube,  and  after  it  begins 
to  operate,  the  heating  of  the  target  will  usually  drive  off 
enough  occluded  gas  so  that  the  vacuum  will  not  rise  above 
the  working  point  when  the  glass  walls  become  cooler  again. 
The  most  effective  point  for  heating  the  bulb  is  in  the  neigh- 
borhood of  the  cathode,  but  this  is  the  point  where  the  greatest 
care  must  be  exercised  in  order  to  avoid  cracking  the  glass. 
If  the  vacuum  of  the  tube  is  very  high,  it  may  be  lowered 
permanently  by  baking  it  for  an  hour  or  two  in  an  oven  at 
a  temperature  of  300°  to  400°  F.  The  tube,  of  course,  must 
not  be  allowed  to  come  in  contact  with  the  metal  parts  of 
the  oven,  and  care  must  be  taken  not  to  lower  the  vacuum 
beyond  the  working  point. 

With  a  static  machine  tubes  that  are  high  in  vacuum  will 
frequently  start  if  a  small  spark  gap  be  opened  on  the  positive 
side  of  the  machine.  Running  the  tube  reversed  for  a  few 
seconds  will  sometimes  lower  the  vacuum,  but  tubes  behave 
so  differently  that  no  fixed  rules  can  be  given  for  managing 
them. 

Punctures. — I  have  already  alluded  to  the  fact  that  under 
certain  conditions  a  spark  may  pass  through  the  glass  bulb 
and  puncture  it.  When  this  occurs,  there  is  usually  a  minute 
hole  or  crack,  which  is  scarcely  discernible,  but  which  is  suffi- 
cient to  allow  air  to  enter  and  destroy  the  vacuum  of  the  tube 
in  a  very  few  minutes.  If  the  tube  is  kept  running  after  it 


38  X-RAY   TUBES. 

is  punctured,  a  series  of  beautiful  effects  will  be  observed, 
and  the  appearance  of  the  discharges  through  varying  degrees 
of  vacuum  may  be  noticed  until  finally  the  bulb  is  full  of  air 
and  sparks  pass  between  the  electrodes.  The  appearance  of 
the  punctured  tube  at  one  stage  is  shown  in  figure  4.  When 
a  tube  is  punctured,  it  should  be  sent  to  the  maker,  who  can 
seal  up  the  hole  and  re-exhaust  the  tube  to  proper  vacuum. 

Testing  the  Tube. — After  the  tube  has  been  in  operation, 
the  first  step  is  to  determine  whether  the  penetration,  definition, 
and  intensity  of  the  rays  are  suitable  for  the  work  to  be  done. 

There  is,  so  far,  no  satisfactory  standard  for  measuring  or 
rating  the  vacuum  of  the  tubes  or  the  penetration  of  the  rays 
obtained  from  them.  Tubes  are  commonly  called  hard,  me- 
dium, or  soft,  according  to  whether  the  penetration  is  high, 
medium,  or  low.  These  terms  do  not  mean  exactly  the  same 
thing  with  any  two  observers.  The  three  examples  of  high,  me- 
dium, and  low  vacuum  tubes  mentioned  above  represent  fairly 
well  these  three  stages. 

A  more  satisfactory  method  of  rating  the  penetration  of  a 
tube  is  to  express  its  resistance  in  terms  of  the  distance  through 
which  a  spark  gap  will  pass  between  the  lead  wires  in  preference 
to  passing  through  the  tube. 

With  a  tube  of  such  low  vacuum  that  the  discharge  rods  may 
be  approached  within  1^  inches  of  each  other  before  the  spark 
passes,  the  hand  will  cast  a  dark  shadow  on  a  brilliantly  illu- 
minated screen,  and  the  shadow  of  the  fleshy  parts  will  be 
dense  enough  to  obscure  to  a  certain  extent  the  shadows  of 
the  bones. 

With  a  medium  tube  the  range  of  the  alternate  spark  gap 
will  probably  be  from  1-|  to  2£  inches,  and  the  shadows  of 
the  bones  will  appear  very  distinct  and  clear,  and  will  be 
slightly  illuminated,  because  they  do  not  obstruct  all  of  the 
rays. 

With  a  tube  of  higher  vacuum  the  resistance  may  be  equiva- 
lent to  an  alternate  spark  gap  of  4  to  7  inches,  and  the  pene- 
tration of  the  rays  may  be  such  that  the  shadows  of  the  bones 
of  the  hand  are  of  a  grayish  color,  with  very  little  contrast 
between  the  bones  and  flesh. 


FIG.  3. — APPEARANCE  OF  X-RAY  TUBE  WHEN  OPERATING  AT 
VERY  Low  VACUUM. 


FIG.  4. — APPEARANCE  OF  DISCHARGE  THROUGH  X-RAY  TUBE 
A  SHORT  TIME  AFTER  THE  BULB  HAS  BEEN  PUNCTURED  OR  CRACKED 
(BULB  PARTIALLY  FILLED  WITH  AIR). 


TESTING    THE    TUBE. 


39 


Testing  the  tube  by  observing  the  shadows  of  the  hand  in 
this  way  is  very  convenient,  but  it  is  not  to  be  recommended 
for  the  reason  that  the  skin  on  the  back  of  the  hand  is  very 
sensitive  to  the  x-rays,  and 
burns  are  perhaps  more 
liable  in  this  area  than 
any  other  part  of  the 
body.  Indeed,  most  men 
who  have  had  much  ex- 
perience in  x-ray  work 
have  had  more  or  less 
difficulty  from  this  cause, 
and  several  have  been 
badly  burned,  necessitat- 
ing in  some  cases  the  am- 
putation of  the  fingers  or 
the  hand.  It  is,  therefore, 
better  to  judge  the  pene- 
tration of  the  tube  from 
the  length  of  the  alternate 
spark  gap,  or  by  its  gen- 
eral appearance.  It  must 
be  borne  in  mind,  however, 
that  the  length  of  the  al- 
ternate spark  gap  for  a 
given  penetration  will  not 
be  exactly  the  same  in 
different  tubes,  and  that 
it  will  vary  somewhat  with 
the  strength  of  the  exciting 
current,  and  will  be  longer 
when  the  current  is  stronger 
than  when  it  is  weak. 

Another  means  of  indi- 


Fig.  5. — Tinfoil  electroscope  for  indi- 
cating the  potential  at  the  terminal  of  a 
Crookes  tube. 


eating  the   penetration  of 

the  tube  is  by  the  use  of  a  modification  of  the  gold-leaf  electro- 
scopes which  I  have  made  for  this  purpose,  and  which  is  shown 
in  figure  5.  In  this  electroscope  the  movable  leaves  are  made 


40 


X-RAY   TUBES. 


of  two  strips  of  tinfoil  about  f  of  an  inch  wide  and  5  inches 
long,  arranged  to  be  suspended  in  the  air.  This  appliance 
is  connected  with  one  of  the  terminals  of  the  exciting  apparatus 
or  one  of  the  lead  wires,  and  indicates  the  potential  at  the 
terminal  of  the  tube  by  the  amount  of  divergence  of  the  leaves. 
When  the  vacuum  of  the  tube  is  low,  the  potential  of  the  lead 
wires  is  correspondingly  low,  and  the  leaves  of  the  electroscope 
separate  only  a  short  distance;  but  with  a  high  resistance 
tube  the  separation  may  be  as  much  as  1^  inches  or  more. 
The  use  of  the  electroscope  is  open  to  the  objection  that  the 
divergence  of  the  leaves  will  vary  to  some  extent  with  the 
strength  of  the  exciting  current  as  well  as  the  potential  of 


1 

2 

3 

4 

5 

6 

7 

8 

9 

IO 

1  1 

12 

13 

14 

15 

16 

Fig.  6. — Device  for  measuring  penetration  of  a>rays. 

the  lead  wires.  However,  it  is  convenient  because  it  gives 
a  constant  indication  of  the  condition  of  the  tube,  and  is  free 
from  the  noise  and  sparks  incident  to  testing  from  time  to 
time  with  the  alternate  spark  gaps. 

The  penetration  may  also  be  tested  by  observing  the  number 
of  leaves  of  tinfoil  which  must  be  interposed  between  the  tube 
and  a  small  piece  of  fluorescent  screen  before  the  rays  are 
entirely  cut  off.  A  number  of  measuring  devices  of  this  sort 
have  been  made,  and  one  of  the  common  forms  is  shown  in 
figure  6.  This  consists  of  a  card  which  may  be  attached  in 
front  of  the  screen  of  a  fluoroscope  and  which  is  covered  with 


RONTGEN 's  PLATINUM-ALUMINUM  WINDOW.  41 

squares  of  tinfoil  in  a  varying  number  of  layers,  and  so  arranged 
that  one  may  observe  at  what  point  the  rays  fail  to  produce 
an  effect  upon  the  screen.  Such  methods  are  exceedingly 
inaccurate,  because  their  readings  will  vary  with  the  sensi- 
tiveness of  the  screen  and  with  the  sensitiveness  of  the  eye. 
The  eyes  of  different  observers  will,  of  course,  be  widely  different, 
and  the  condition  of  the  retina  of  one  observer  will  be  very 
different  at  different  times,  depending  upon  the  amount  of 
exposure  to  light  immediately  preceding  the  observation. 

The  platinum-aluminum  window  of  Rontgen  is  the  only 
means  which  has  been  suggested  for  accurately  measuring 
and  standardizing  the  penetrating  quality  of  the  x-rays.  Ap- 
parently, this  method  is  free  from  errors  due  to  the  differences 
in  the  sensitiveness  of  the  eye,  the  efficiency  of  the  screens, 
or  the  intensity  of  the  ray. 

Rontgen 's  original  platinum-aluminum  window  is  described 
in  his  third  paper  as  follows:  "A  rectangular  piece  4  by  6.5 
cm.  of  platinum-foil  of  0.0026  mm.  thickness,  which  is  cemented 
to  a  thin  paper  screen,  and  through  which  are  punched  15 
round  holes,  arranged  in  3  rows,  each  hole  having  a  diameter 
of  0.7  cm.  These  little  windows  are  covered  with  panes  of 
aluminum,  0.0299  mm.  thick,  which  fit  exactly,  and  are  super- 
imposed in  such  a  way  that  at  the  first  window  there  is  1  disc; 
at  the  second,  2,  etc.;  finally,  at  the  fifteenth,  15  discs.  If 
this  arrangement  be  brought  in  front  of  the  fluorescent  screen, 
it  may  be  observed  very  plainly,  in  case  the  tubes  are  not  too 
hard,  how  many  aluminum  sheets  have  the  same  transparency 
as  the  platinum-foil.  The  number  will  be  called  the  window 
number. 

"  For  the  window  number  I  obtained  in  one  case  by  direct 
radiation  the  value  5.  A  plate  of  common  soda  glass,  2  mm. 
thick,  was  then  held  in  front — the  window  number  was  10. 
So  that  the  ratio  of  the  thickness  of  the  platinum  and  aluminum 
sheets  of  equal  transparency  was  reduced  one-half  when  I 
used  rays  which  had  passed  through  a  plate  of  glass  2  mm. 
thick  instead  of  using  those  coming  direct  from  the  discharging 
apparatus. 

"The  ratio  of  the  thickness  of  two  equally  transparent  plates 


42  X-RAY  TUBES. 

of  different  substances  is  also  dependent  upon  the  hardness 
of  the  tube  used.  This  may  be  recognized  immediately  with 
the  platinum-aluminum  window;  with  a  very  soft  tube,  for 
example,  the  window  number  may  be  found  to  be  2;  while 
with  a  tube  which  is  very  hard  but  otherwise  the  same,  the 
scale  which  reaches  15  does  not  extend  far  enough.  This 
means,  then,  that  the  ratio  of  the  thickness  of  platinum  and 
aluminum  of  equal  transparency  is  smaller  in  proportion  as 
the  tubes  from  which  the  rays  come  are  harder  or — with  refer- 
ence to  the  results  reported  above — as  the  rays  are  less  easily 
absorbed."* 

It  is  to  be  hoped  that  the  x-ray  societies  will  take  up  this 
matter  of  standardizing  the  quality  of  the  rays  delivered  b}^ 
the  x-ray  tubes,  and  adopt  a  standard  apparatus  based  on 
this  principle.  The  use  of  it  will  enable  one  to  accurately 
describe  the  quality  of  the  ray  which  is  employed.  At  present 
this  is  quite  impossible. 

Some  idea  of  the  definition  of  the  tube  may  be  obtained 
by  observing  the  shadow  of  the  hand  in  the  fluoroscope.  A 
tube  with  good  definition  will  always  give  sharp,  clear  shadows. 
When  it  gives  a  blurred  or  indistinct  image  of  the  hand,  it 
has  not  sufficiently  good  definition  for  either  radiographic  or 
fluoroscopic  work.  A  better  method  of  testing  the  definition 
of  a  tube  is  to  hold  the  fluoroscope  with  the  screen  at  about 
18  inches  from  the  target  of  the  tube,  and  move  back  and 
forth  between  the  screen  and  the  tube  a  small  metallic  object 
such  as  a  key  or  a  piece  of  heavy  wire  gauze.  It  will  be  ob- 
served that  when  the  object  is  in  contact  with  the  screen  the 
shadows  are  very  sharp,  but  as  it  is  moved  further  and  further 
away  from  the  screen  and  closer  to  the  tube  the  shadows  become 
larger  and  at  the  same  time  the  margins  become  less  sharp 
and  distinct. 

A  tube  which  has  sufficiently  good  definition  for  making 
radiographs  of  the  hip-joint  or  shoulder  should  show  these 
outlines  sharply  when  the  key  or  wire  gauze  is  held  at  a  distance 
of  8  inches  from  the  screen  with  the  screen  not  more  than 
18  inches  from  the  target  of  the  tube.  Good  definition  will 

*  From  Rontgen's  third  paper. 


THE    CHOICE    OF    AN    X-RAY   TUBE.  43 

usually  be  obtained  from  a  tube  which  is  well  focused,  and 
such  a  tube  may  be  detected  by  observing  the  manner  in  which 
the  target  heats  up  when  it  is  started.  If  the  heating  begins 
with  an  exceedingly  small  red-hot  point  on  the  target,  this 
is  an  indication  that  the  tube  is  accurately  focused. 

It  is  well  to  mark  the  tubes  in  some  way  after  they  have 
been  tested,  and  to  reserve  those  which  are  of  bad  definition 
for  therapeutic  purposes. 

The  Choice  of  an  X-ray  Tube. — The  choice  of  x-ray  tubes 
is  a  matter  upon  which  operators  have  widely  different  opinions, 
and  I  therefore  describe  here  a  number  of  tubes  representing 
the  principal  types  employed  by  the  most  successful  operators. 
Of  the  different  varieties  some  are  better  adapted  for  one 
purpose  and  some  for  another,  and  it  is  therefore  advisable 
to  have  two  or  three  kinds  of  tubes  in  one's  collection. 


ANODE 


Fig.  7. — Jackson  single  focus  tube. 

In  a  good  tube  the  glass  should  be  smooth  and  free  from 
uneven  spots,  the  electrodes  should  be  well  made  and  strongly 
supported  so  that  they  do  not  rattle  when  the  tube  is  shaken. 
The  terminals  for  connecting  the  lead  wires  should  be  strong 
and  so  supported  that  they  will  not  be  liable  to  be  bent  or 
broken  in  use. 

For  x-ray  treatment,  for  fluoroscopic  examinations,  and  for 
radiographic  work  where  the  fastest  exposures  are  not  required, 
it  is  perhaps  better  to  use  the  less  complicated  forms  of  tubes. 
The  simplest  and  one  of  the  best  of  these  is  the  ordinary  Jackson 
single  focus  tube  which  is  shown  in  figure  7.  These  tubes  are 
sold  by  nearly  all  the  makers,  and  they  differ  much  in  effective- 
ness according  to  the  care  which  has  been  taken  in  mechanical 
construction  and  in  the  exhaustion. 


44 


X-RAY   TUBES. 


Bi-anode  Tube. — Many  of  the  tubes  of  German  manufacture 
have  in  addition  to  the  two  electrodes  of  the  tube  shown  above, 
a  third  which  may  be  connected  in  various  ways.  This  type 
(shown  in  figure  8)  is  probably  used  more  than  any  other. 
The  third  electrode  gives  us  some  advantage  in  the  regulation 
of  the  resistance.  The  highest  resistance  will  be  obtained  by 
connecting  the  negative  wire  to  the  cathode  A,  and  the  positive 


Fig.  8.—"  Bi-anode  "  tube. 


Fig.  9. — Penetrator  tube. 


wire  to  the  target  terminal  B.  When  the  positive  wire  is 
connected  to  the  third  electrode  C  alone,  the  current  will  pass 
much  more  readily,  and  the  rays  will  be  of  lower  penetration. 
Penetration  intermediate  between  these  two  points  can  be 
obtained  by  connecting  the  terminals  of  the  target  and  the 
electrode  C  together,  both  being  connected  with  the  positive 
wire. 


THOMSON   TUBE  45 

Penetrator  Tube. — This  tube  is  made  by  Miiller  and  others 
and  is  shown  in  figure  9.  It  is  based  upon  the  principle  that 
with  a  given  vacuum  the  penetration  will  be  higher  the  closer 
the  electrodes  are  together.  In  this  tube  a  ring  of  metal  is 
extended  out  from  the  target  to  a  point  between  it  and  the 
cathode.  Such  tubes  are  preferred  by  some  operators  for 
fluoroscopic  work  in  which  a  very  high  penetration  is  desired. 

Tubes  with  Vacuum  Regulators. — Devices  for  regulating  and 
controlling  the  vacuum  were  among  the  first  developments 
of  Crookes  tubes  for  x-ray  work.  One  of  the  first  methods 
employed  was  that  which  had  been  used  by  Crookes  in  his 
early  experiments,  and  consists  in  providing  a  tube  with  an 
auxiliary  chamber  containing  potassium  or  sodium  hydrate. 
By  applying  heat  to  this  auxiliary  bulb  a  certain  amount  of 


Fig.  10. —Thomson's  vacuum  regulator  tube. 

the  water  of  crystallization  of  the  salt  is  driven  off  and  lowers 
the  vacuum.  When  the  bulb  cools  again,  the  vapor  is  re- 
absorbed.  Thus  a  considerable  range  of  regulation  of  the 
vacuum  may  be  obtained. 

Thomson  Tube. — Elihu  Thomson  applied  this  method  of 
regulation  to  tubes  for  x-ray  work,  and  modified  it  by  sealing 
a  platinum  electrode  through  the  auxiliary  bulb  so  that  the 
vapor  could  be  liberated  by  passing  sparks  through  the  salt. 
This  tube  is  shown  in  figure  10.  Regulation  of  this  tube  may 
be  made  automatic  by  carrying  a  wire  from  the  terminal  of 
the  auxiliary  chamber  to  a  point  a  few  inches  from  the  negative 
wire  of  the  exciting  apparatus.  When  the  vacuum  of  the 
tube  rises  to  such  a  point  that  the  discharge  passes  with  difficulty 
between  the  anode  and  cathode,  a  spark  will  jump  from  the 


46 


X-RAY   TUBES. 


negative  wire  to  the  wire  connecting  with  the  auxiliary  chamber. 
After  the  discharge  has  passed  through  the  auxiliary  chamber 
for  a  little  while  the  vacuum  of  the  tube  will  be  lowered,  and 
the  discharge  will  again  pass  through  the  main  terminals  of 
the  tube.  It  is  obvious  that  the  degree  of  vacuum  which 
will  be  maintained  by  this  method  will  depend  upon  the  distance 
through  which  the  regulating  spark  must  pass.  If  this  distance 
is  made  very  small,  the  discharge  passes  readily  through  the 
regulator  and  a  low  vacuum  will  be  maintained;  but  if  the 
regulating  spark  gap  is  long,  the  vacuum  of  the  tube  may 
have  to  become  very  high  before  the  sparks  will  pass  through 
the  regulator  to  reduce  it. 

Bario-vacuum  Tube  and  Regulator. — The  bario-vacuum  tube 
shown  in  figure  11  is  operated  on  precisely  the  same  principle 


Fig.  11. — Bario-vacuum  tube  with  regulator. 

as  the  one  just  described,  but  the  auxiliary  regulating  chamber 
is  placed  at  the  end  of  the  bulb  directly  opposite  the  cathode. 
It  is  designed  for  automatic  regulation  by  the  method  above 
described,  and  the  regulating  spark  gap  is  enclosed  in  a  hard- 
rubber  tube  for  the  purpose  of  lessening  the  noise  and  concealing 
the  flashes  of  light.  The  sliding  rod  extending  from  the  end 
of  the  regulator  tube  enables  the  length  of  spark  gap  to  be 
adjusted  for  any  degree  of  vacuum. 

Sayen  Tube. — In  1896  Mr.  Sayen  patented  a  tube  with  an 
automatic  vacuum  regulator,  and  which  is  sold  as  the  Queen 
Self-regulating  Tube.  This  tube  is  shown  in  figure  12,  and 
described  in  Queen's  catalogue  as  follows: 


SAYEN   TUBE. 


47 


"  A  small  bulb,  X,  containing  a  chemical  which  gives  off  vapor 
when  heated  and  reabsorbs  it  when  it  cools,  is  directly  con- 
nected to  the  main  tube,  B,  and  is  surrounded  by  an  auxiliary 
tube,  D,  which  is  exhausted  to  a  low  Crookes  vacuum.  In  the 
auxiliary  tube  the  cathode  is  opposite  to  the  above-mentioned 
bulb,  so  that  any  discharge  through  it  will  heat  the  bulb  by  the 
bombardment  of  the 
cathode  rays.  This  cath- 
ode  is  connected  to  an 
adjustable  spark  point, 
P,  the  end  of  which 
may  be  swung  to  any 
desired  distance  from 
the  cathode,  K,  of  the 
main  tube.  The  anode  of 
the  small  tube  is  directly 
connected  to  the  anode, 
A,  of  the  main  tube. 
The  coil  is  connected  as 
usual  to  the  main  tube, 
which  has  been  ex- 
hausted to  a  very  high 
vacuum,  and  conse- 
quently has  a  high  re- 
sistance equal  to  ten 
inches  of  air  or  more. 
When  it  is  put  in  opera- 
tion, the  vacuum  of  the 
main  tube  being  high, 
and  consequently  hav- 
ing high  resistance,  the 

current  takes  the  path  of  least  resistance  by  the  spark  point 
and  the  auxiliary  tube,  which,  being  a  low  Crookes  vacuum, 
has  a  very  small  resistance,  and  heats  the  chemical  in  the 
small  bulb,  X,  thereby  releasing  the  vapor  which  it  contains  in 
state  of  absorption  and  driving  it  into  the  main  tube,  B.  This 
will  continue  for  a  few  seconds  until  a  sufficient  amount 
of  vapor  has  been  driven  into  the  main  tube  to  permit 


Fig.  12.— Sayen's  self-regulating  tube. 


48  X  RAY   TUBES. 

the  current  to  go  through  it,  which  will  begin  to  take  place 
when  the  vacuum  has  been  reduced  until  the  resistance  of 
the  main  tube  is  brought  down  to  that  of  the  spark  gap  plus 
the  small  resistance  of  the  auxiliary  bulb.  After  this  only  an 
occasional  spark  will  jump  across  the  gap  to  counteract  the 
tendency  of  the  chemical  as  its  bulb  cools  to  reabsorb  vapor 
and  raise  the  resistance  of  the  main  tube.  The  tube  is  thus 
maintained  at  a  constant  vacuum  while  running.  When  the  cur- 
rent is  stopped  the  chemical  cools  off  and  reabsorbs  vapor  and 
the  tube  returns  to  its  starting  condition  of  high  vacuum. 

' '  It  will  be  evident  from  the  above  that  the  height  of  the 
vacuum  at  which  the  tube  runs  will  depend  on  the  resistance 
of  the  circuit  through  the  auxiliary  bulb — in  other  words,  on 
the  length  of  the  spark  gap.  The  tube  may  be  set  to  run  at 
high  vacuum  by  placing  the  spark  point  at  a  considerable  dis- 
tance from  the  cathode  terminal  of  the  main  tube,  or  to  run 
low  by  placing  it  near.  The  adjustability  of  the  vacuum  is 
of  the  utmost  importance,  as  the  penetrating  power,  photo- 
graphic effect,  and  ability  to  brilliantly  light  a  fluorescing 
screen  all  depend  upon  the  degree  of  exhaustion,  and  that 
degree  of  vacuum  which  is  best  for  one  operation  is  not  best 
for  another." 

This  regulator  is  very  satisfactory  when  the  tube  is  to  be 
used  for  a  considerable  period  of  time — two  to  three  minutes. 
It  has  the  disadvantage  that  the  conduction  of  heat  through 
the  glass  walls  of  the  auxiliary  chamber  requires  an  appreciable 
time,  and  before  the  sparks  in  the  auxiliary  chamber  stop  so 
much  heat  has  been  stored  up  in  the  glass  of  the  auxiliary 
chamber  that  the  vapor  continues  to  come  off  after  the  regu- 
lating sparks  have  ceased.  When  the  tube  is  first  started, 
therefore,  there  is  a  tendency  for  the  vacuum  to  become  much 
lower  than  is  desired.  After  a  few  minutes'  running,  however, 
the  vacuum  chamber  attains  fairly  constant  temperature,  and 
only  occasional  sparks  through  the  auxiliary  chamber  are 
necessary  for  further  regulation.  When  this  condition  is 
reached  (usually  after  one  or  two  minutes),  the  tube  is  quite 
steady,  and  any  degree  of  vacuum  may  be  automatically 
maintained. 


MULLER  S    REGULATING    TUBE. 


49 


Miiller's  Regulating  Tube. — A  tube,  similar  in  some  respects 
to  the  Sayen  tube,  is  manufactured  by  Miiller,  of  Hamburg, 
and  is  shown  in  figure  13.  This  tube  has  an  auxiliary  chamber 
and  an  adjustable  regulating  spark  gap,  but  it  differs  from 
the  Sayen  tube — having  the  regulating  discharge  pass  directly 


Fig.  13. — Miiller's  heavy  target  tube  with  automatic  vacuum  regulator. 

into  the  auxiliary  chamber  instead  of  through  a  second  vacuum 
chamber.  In  Miiller's  tube  the  regulating  discharge  passes 
through  a  bundle  of  mica  discs,  and  lowers  the  vacuum  of 
the  tube  by  driving  off  occluded  gas  from  them  instead  of 
liberating  vapor  of  crystallization  from  a  salt,  as  in  Sayen  s 

4 


50  X-RAY   TUBES. 

tube.  The  action  of  this  regulator  is  not  delayed  by  the  slow 
conduction  of  heat  through  the  glass  of  the  auxiliary  chamber, 
and  is  therefore  a  little  quicker.  Another  feature  of  the  Miiller 
regulator  is  the  arrangement  for  raising  the  vacuum  of  the 
tube  when  it  becomes  too  low.  This  is  accomplished  by  dis- 
connecting the  wire  from  the  anode,  G,  of  the  tube  proper  and 
connecting  to  the  terminal,  J,  of  the  palladium  electrode  within 
the  auxiliary  chamber.  The  discharge  which  passes  under 
these  conditions  causes  more  gas  to  be  occluded  on  the  palla- 
dium electrode.  Thus  the  vacuum  of  the  tube  may  be  some- 
what increased. 

One  disadvantage  of  all  automatic  regulators  in  which  the 
lowering  of  the  vacuum  is  effected  by  allowing  the  discharge 
to  pass  through  a  by-path  is  that  while  the  regulating  sparks 


Fig.  14. — Gundelach's  heavy  target  tube  with  osmosis  regulator. 

are  passing  there  is  no  discharge  through  the  tube  proper. 
The  target  then  cools  a  little,  and  occludes  upon  its  surface 
some  of  the  gas.  The  regulation  continues  until  its  proper 
vacuum  is  obtained  with  the  target  cooled,  and  as  soon  as 
the  discharge  passes  again  through  the  tube  the  target  heats 
up  and  may  drive  off  enough  gas  to  make  the  vacuum  too 
low.  In  other  words,  while  the  regulator  is  in  operation  the 
current  is  taken  away  from  the  tube  proper,  and  the  adjustment 
of  the  vacuum  is  made  under  conditions  which  are  somewhat 
different  from  those  when  the  whole  discharge  is  passing  through 
the  tube. 

Tubes  with  Osmosis  Regulators. — Another  method  of  regu- 
lating the  vacuum  depends  upon  the  fact  that  certain  metals, 
such  as  platinum,  become  porous  when  heated  to  a  red  heat. 


HIRSCHMANN  S   TUBE. 


51 


A  closed  tube  of  platinum  may  be  sealed  into  the  bulb  of  an 
x-ray  tube,  and  when  cold,  it  will  be  perfectly  tight.  When 
the  vacuum  of  the  tube  becomes  too  high,  the  little  platinum 
tip  may  be  heated  to  a  red  heat  by  a  spirit  lamp  for  a  few 
minutes,  and  the  temperature  of  the  metal  will  rise  and  allow 
a  little  gas  to  enter  through  its  pores  into  the  bulb,  and  thus 
lower  the  vacuum.  This  type  of  regulator  has  been  used  by 
a  number  of  makers.  One  of  Gundelach's  tubes  with  such  a 
regulator  is  shown  in  figure  14.  Another  one  is  the  "osmo- 
regulator"  tube  of  Dean,  shown  in  figure  15.  It  is  said  that 


Fig.  15. — Dean's  "  osmo-regulator  "  tube,  showing  method  of  reducing  the 

vacuum. 


with  this  regulator  the  vacuum  of  the  tube  may  be  permanently 
lowered.  It  is  very  highly  recommended  by  some  operators 
who  use  it. 

Hirschmann's  Tube. — In  this  tube  the  vacuum  may  be  lowered 
by  turning  the  valve  A,  which  admits  a  small  amount  of  air 
into  the  bulb.  The  tube  is  also  provided  with  an  auxiliary 
chamber,  B,  which  is  coated  on  the  inside  with  a  substance 
which  may  be  made  to  occlude  a  considerable  amount  of  gas 
when  the  current  is  passed  through  the  electrode  C.  The  object 
of  this  device  is  to  enable  the  vacuum  to  be  raised.  Lowering 


52  X-RAY   TUBES. 

the  vacuum  by  the  admission  of  air  through  the  valve  does 
not,  of  course,  admit  of  very  fine  adjustment  (see  Fig.  16). 

Water-cooled  Tubes. — Water-cooled  tubes  have  been  produced 
by  a  number  of  makers,  and  a  typical  one  is  that  of  Miiller, 
shown  in  figure  17.  Water-cooled  tubes  with  a  bottle  for 
containing  the  cooling  liquid  are  preferable  to  those  in  which 
the  liquid  is  circulated.  The  circulating  pipes  and  reservoirs 
are  clumsy,  and  if  water  is  used,  the  difficulty  of  insulating 
them  is  to  be  considered. 

Tubes  with  Heavy  Targets. — A  tube  of  M  tiller's  which  is 
designed  for  use  with  very  strong  exciting  currents  is  shown 
in  figure  13.  It  does  not  differ  essentially  from  the  other 


Fi^.  10. — Hirschmann's  tube  with  valve  for  admitting  air  to  lower  the  vacuum. 

bi-anode  tubes,  except  that  the  target  contains  a  large  mass 
of  metal  having  large  thermal  capacity  and  does  not  become 
quickly  heated. 

Gundelach's  heavy  target  tube  for  use  with  electrolytic  inter- 
rupters is  shown  in  figure  14.  In  this  tube  the  target  is  made 
of  a  heavy  mass  of  metal  usually  faced  with  a  thin  sheet  of 
platinum,  and  provided  with  a  long  tubular  projection  of 
metal  which  is  designed  to  increase  the  radiating  surface. 
This  tubular  projection  is  blackened  for  the  purpose  of  facili- 
tating the  radiation  of  heat  from  the  target. 

Both  of  these  tubes  are  excellent  for  short  exposures,  with 
the  heavy  discharges  obtained  from  induction  coils  operated 
with  electrolytic  interrupters. 


VOLT-OHM   TUBE. 


53 


A  heavy  target  tube,  made  by  the  Volt-Ohm  Co.,  is  shown 
in  figure  18.  This  tube  is  of  the  modified  bi-anodic  type, 
having  a  second  electrode  enclosed  within  a  bulbous  enlarge- 
ment of  the  neck  of  the  tube.  In  this  tube  the  discharge 
passes  very  much  more  readily  when  the  positive  wire  is  con- 


Fig.  17. — Miiller's  tube  with  water-cooled  target. 

nected  with  the  auxiliary  anode  than  when  it  is  connected 
with  the  target.  The  target  of  this  tube  is  made  of  a  disc 
of  copper  I  of  an  inch  thick,  and  faced  with  a  thin  sheet  of 
platinum. 


54 


X-RAY   TUBES. 


Double-focus  Tubes. — The  tubes  described  in  the  preceding 
pages  are  adapted  for  undirectional  discharges,  and  are  called 
single-focus  tubes  from  the  fact  that  they  have  one  cathode 
and  one  focus  point  upon  the  target.  With  high-frequency 
apparatus  and  other  exciting  apparatus  which  give  discharges 


Fig.  18.— Volt-Ohm  tube. 


Fig.  19. — Thomson's  double-focus 
tube. 


alternating  in  direction,  it  is  better  to  use  a  tube  which  operates 
equally  well  with  the  current  flowing  through  it  in  either 
direction.  Such  a  tube  is  shown  in  figure  19.  The  tubes 
are  constructed  so  as  to  bring  the  focus  points  of  the  two  con- 
cave electrodes  as  near  together  on  the  target  as  possible, 


TUBES    FOR   THERAPEUTIC    USES.  55 

in  order  to  secure  good  definition.  In  using  such  a  tube  the 
terminals  of  the  exciting  apparatus  are  connected  with  the 
two  cup-shaped  electrodes.  "With  the  changes  in  the  direction 
of  the  exciting  current  each  electrode  becomes  alternately 
the  anode  and  cathode,  and  the  x-rays  originate  from  the 
target  alternately  from  the  focus  points  of  these  two  electrodes. 

Double-focus  tubes  have  never  been  very  satisfactory.  It 
is  impossible  to  secure  with  them  as  good  definition  as  may 
be  obtained  with  single-focus  tubes.  It  is  more  difficult  to 
regulate  and  maintain  the  vacuum,  and  blackening  of  the 
bulb  is  much  more  rapid  than  with  single-focus  tubes.  At 
present  they  are  used  for  therapeutic  purposes  when  the  avail- 
able exciting  apparatus  produces  alternating  discharges. 

Tubes  for  Therapeutic  Uses. — Any  of  the  ordinary  forms  of 
tubes  may  be  used  for  therapeutic  purposes.  The  selection 
of  a  tube  for  this  work  is  a  comparatively  easy  matter,  definition 
is  a  matter  of  no  importance  whatever,  and  the  regulation 
of  the  vacuum  need  not  be  so  accurate  as  is  necessary  for 
fluoroscopic  or  radiographic  work. 

For  treatment  in  cavities  of  the  body — mouth,  rectum, 
vagina,  etc., — a  number  of  special  forms  of  tubes  have  been 
designed.  For  treating  the  cervix  uteri  some  operators  employ 
the  ordinary  single-focus  tube,  placing  it  in  line  with  a  metallic 
speculum  introduced  into  the  vagina.  With  this  method  it 
is  sometimes  difficult  to  maintain  the  source  of  light  in  the 
proper  relation  with  the  speculum;  the  slightest  change  in  the 
position  of  the  patient  being  sufficient  to  cut  off  the  rays  from 
the  affected  area. 

To  avoid  this  difficulty  Cossar,  of  London,  has  made  a  single- 
focus  tube  having  a  projecting  ampulla  which  may  be  inserted 
into  the  vagina,  and  thus  keep  the  tube  in  proper  relation 
with  the  part.  The  walls  of  the  tube  are  made  of  lead  glass, 
which  is  comparatively  opaque  to  the  x-rays  except  at  the 
end  of  the  ampulla  which  comes  opposite  to  the  part  under 
treatment,  where  the  glass  is  thinner  and  of  a  composition 
which  allows  the  rays  to  penetrate  it  readily.  This  tube  is 
shown  in  figure  20. 

Another  difficulty  of  the  single-focus  tube  and  of  tubes  of 


56 


X-RAY    TUBES. 


Fig.  20. — Cossar's  tube  for  therapeutic  uses. 


the  type  just  described  is  due  to  the  fact  that  the  x-rays  proceed 
in  straight  lines  and  cannot  be  appreciably  reflected  or  re- 
fracted; consequently,  it  is  impossible  with  them  to  apply  the 

rays  to  parts  which  can- 
not be  brought  directly 
in  line  with  the  target, 
which  is,  of  course,  out- 
side the  body. 

In  order  to  apply  the 
rays  directly  to  the  lar- 
ynx and  certain  other 
points  upon  which  the 
rays  cannot  be  thrown 
directly  by  the  ordinary 
single-focus  tube,  I  have 

devised  some  tubes  in  which  the  source  of  ray  is  at  the  end  of 
a  tubular  projection  which  may  be  inserted  within  a  cavity  of 
the   body,  and  from  there  send  out  rays  in  every  direction. 
These  tubes  are  shown  in  figures 
21,  22,  23,  and  24. 

In  the  tube  shown  in  figure  21  the 
target,  T,  is  completely  insulated 
and  the  anode,  A,  is  placed  at  the 
end  of  a  third  tubular  projection 
from  the  spherical  part. 

If  the  positive  terminal  of  the 
exciting  machine  is  connected  to  a 
ground  wire,  the  tubular  projec- 
tion carrying  the  anode  may  be 
used  as  a  handle  and  no  shock 
will  be  felt  either  by  the  operator 
or  the  patient  when  the  machine 
is  in  operation.  This  form  of  tube 
may  be  used  without  any  special 
device  for  holding  it,  and  the  tub- 
ular projection  carrying  the  target  may  be  readily  introduced 
through  any  of  the  common  forms  of  vaginal  and  rectal  specula, 
for  applying  the  rays  directly  to  the  cervix,  the  vagina,  the 


Fig.  21. — Tube   for  x-ray   treat- 
ment of  larynx,  etc. 


TUBES    FOR    THERAPEUTIC    USES. 


57 


rectum,  or  the  prostate  gland  through  the  rectum.  Since  the 
outer  surface  is  of  smooth  glass,  it  may  easily  be  cleansed  and 
sterilized.  In  the  tubes  for  use  in  the  mouth  the  glass  is  flat- 
tened behind  the  target.  This  enables  the  target  to  be  brought 
very  close  to  the  soft  palate,  and  in  just  about  the  position 
occupied  by  a  laryngoscopic  mirror.  It  is  obvious  that  with  the 
target  in  this  position  the  rays  will  fall  directly  upon  every  part 
that  can  be  seen  in  such  a  mirror.  The  tube  shown  in  figure  22 


Fig.  22.— Tube  for 
a>ray  treatment,  for 
use  with  shield. 


Fig.  23. — Handle,  shield,  short-circuiting  switch,  and 
tube. 


is  similar  in  appearance  to  the  first  one,  but  the  target  is  pro- 
vided with  a  connecting  wire  extending  through  the  glass,  and 
may  therefore  be  made  the  anode.  With  this  form  of  tube  it  is 
desirable  to  use  the  shield  and  handle  shown  in  figure  23.  The 
shield  is  a  tubular  hood  of  sheet-metal  which  slips  over  the 
projection  carrying  the  target  and  performs  several  important 
functions.  It  protects  the  glass  against  breakage;  it  contains 


58 


X-RAY    TUBES. 


WATER  TIGHT  J01HT 


an  aperture  through  which  the  x-rays  pass,  and  therefore  limits 
the  area  exposed  to  their  action;  and,  finally,  it  makes  contact 
with  the  connecting  wire  of  the  target  and  completes  the 
electrical  connection  between  the  target  and  the  handle,  which 
is,  of  course,  connected  to  the  positive  terminal  of  the  exciting 
machine  and  to  ground. 

The  metal  handle  also  supports  the  shield  and  the  tube, 
and  is  provided  with  a  switch  so  placed  that  it  can  be  operated 
by  the  thumb,  and  arranged  to  ground  the  negative  wire,  thus 
short-circuiting  the  tube,  stopping  the  x-ray,  and  at  the  same 
time  making  both  wires  safe  to  handle  even  while  the  exciting 
apparatus  is  in  operation. 

If  a  strong  exciting  current  be  used,  the  target  ends  of  these 

tubes  very  quickly  be- 
come hot.  However,  it 
should  be  remembered 
that  with  these  tubes 
the  source  of  x-ray  is 
brought  five  or  ten 
times  closer  to  the  part 
under  treatment  than  is 
possible  with  the  ordi- 
nary x-ray  tube.  Now, 
since  the  effects  of  the 
rays  decreases  approxi- 
mately as  the  squares  of 
the  distance  from  their  source,  it  is  not  necessary  with  these 
tubes  to  use  a  strong  exciting  current,  or  to  make  long  ex- 
posures. 

If  an  induction  coil  is  used  with  this  apparatus,  a  series 
spark  gap  of  one  or  two  inches  should  be  included  in  the  circuit 
to  prevent  short-circuiting  the  secondary  winding  of  the  coil 
when  the  tube  is  short-circuited  by  the  switch  at  the  handle. 

Figure  24  shows  another  tube  of  this  sort  with  modifications 
which  adapt  it  especially  for  uterine  and  vaginal  work.  It 
will  be  noticed  that  in  this  tube,  as  in  the  old  pear-shaped 
tube  of  Crookes,  the  cathode  stream  impinges  not  upon  a 
metal  target,  but  upon  the  glass  wall  of  the  bulb,  which  there- 


Fig.  24. — Tube  for  x-ray  treatment  of  cervix 
uteri. 


TUBES  FOR  THERAPEUTIC  USES.  59 

fore  becomes  the  source  of  the  x-rays.  There  is  also  a  con- 
siderable amount  of  heat  developed  at  the  point  of  impact 
of  the  cathode  stream,  and  it  is  therefore  necessary  to  cover 
the  target  end  of  the  tube  with  a  water-jacket  in  order  to 
keep  it  cool. 

As  indicated  by  the  arrows  in  figure  24,  the  rays  emanate 
from  the  end  of  this  tube  in  every  direction — a  condition  which 
seems  desirable  in  the  treatment  of  most  cases  of  cancer  of 
the  cervix  of  the  uterus,  and  which  is  really  the  only  essential 
difference  between  this  tube  and  the  original  type  shown  in 
figure  21.  If  it  is  desired  to  limit  the  delivery  of  x-rays  to 
any  part  of  the  area  on  which  this  tube  is  used,  it  can  be  done 
by  removing  the  water-jacket  and  covering  the  corresponding 
part  of  the  end  of  the  tube  with  thick  metal  foil.  The  water- 
jacket  may  then  be  replaced  and  the  tube  is  ready  for  use. 
A  number  of  jackets  of  different  shapes  for  different  cases 
may  be  used  upon  the  same  tube. 


CHAPTER  III. 

INDUCTION  COILS,  INTERRUPTERS,  AND  THEIR 
MANAGEMENT. 

THE  induction  coil  has  probably  been  used  more  than  any 
other  apparatus  for  exciting  x-ray  tubes.  It  has  the  advantage 
that  it  is  not  materially  affected  by  atmospheric  changes, 
A  fair-sized  induction  coil  occupies  comparatively  small  space, 
and  it  will  deliver  more  energy  than  can  be  obtained  from 
any  static  machine  which  has  been  built.  For  this  reason 
it  is  particularly  well  adapted  for  radiographic  work. 

Induction  Coil. — The  induction  coils  sold  for  x-ray  work 
all  follow  the  same  general  lines,  and  differ  only  in  size,  in 
their  relative  proportions,  and  in  the  method  of  insulation. 
The  coils  are  rated  according  to  the  length  of  sparks  which 
may  be  obtained  from  them,  and  the  smallest  coils  that  may 
be  used  in  practical  work  are  rated  at  about  6-inch  spark 
length.  Such  a  coil  has  a  core  about  12  inches  long,  and  about 
1^  inches  in  diameter;  the  coil  complete  weighs  perhaps  30 
pounds.  Such  a  coil  may  be  operated  on  about  two  cells  of 
storage  battery. 

The  largest  coils  that  are  made  regularly  for  x-ray  work 
are  rated  at  40  inches  spark  length.  They  are  very  massive 
machines  weighing  several  hundred  pounds,  and  have  a  length 
of  core  of  about  7  or  8  feet.  Between  these  two  extremes  there 
are  a  great  many  intermediate  sizes.  The  ones  most  commonly 
used  are  rated  from  10  to  18  inches  spark  length. 

Winding  of  the  Primary. — The  primary  windings  in  the  coils 
of  different  makers  vary  considerably,  and  of  course  will  be 
different  according  to  the  source  of  electrical  energy  with  which 
they  are  to  be  supplied.  In  the  coils  which  are  to  be  operated 
from  storage  batteries  it  is  customary  to  have  but  one  layer 
of  very  coarse  wire  in  the  primary  winding.  This  allows  the 
coil  to  be  operated  with  a  comparatively  small  number  of 

60 


INSULATION    BETWEEN    THE    PRIMARY   AND    SECONDARY.       61 

cells.  Coils  which  are  to  be  operated  from  the  110- volt  direct 
current  lighting  circuits  often  have  in  the  primary  winding 
as  many  as  four  layers,  with  as  many  as  500  or  600  turns  of 
wire.  Such  coils  will,  of  course,  require  smaller  strength  of 
exciting  current  for  a  given  output,  but  the  current  must  be 
supplied  at  a  comparatively  high  electro-motive  force. 

In  some  of  the  newest  types  of  coils  there  are  four  layers 
in  the  primary  windings,  and  the  ends  of  these  layers  are  brought 
out  to  terminals  in  such  a  way  that  they  may  be  connected 
in  various  combinations  of  series  and  parallel  so  that  an  equiva- 
lent number  of  turns  of  one,  two,  or  four  layers  may  be  em- 
ployed. This  adjustment  enables  the  coil  to  be  adapted  to 


Fig.  25. — Induction  coil  with  arrangement  for  connecting  primary  windings  in 

series  and  parallel. 

sources  of  current-supply  of  different  potentials,  and  it  also 
gives  a  certain  amount  of  adjustment  of  the  coil  to  suit  the 
resistance  of  the  tube  which  is  used.  Figure  25  shows  a  coil 
in  which  any  connection  of  the  primary  is  made  by  inserting 
various  plugs  in  sockets  on  the  end  of  the  core. 

Insulation  between  the  Primary  and  Secondary. — Obviously 
it  is  necessary  that  the  insulation  between  the  primary  and 
secondary  windings  must  be  of  such  a  character  that  the  sparks 
from  the  secondary  will  not  penetrate  it.  In  the  majority 
of  coils  this  is  accomplished  by  using  a  hard-rubber  tube  which 
fits  closely  over  the  primary  winding,  and  extends  to  the  end 
of  the  core.  The  thickness  of  this  tube  will  depend  upon 


62  INDUCTION    COILS    AND    INTERRUPTERS. 

the  length  of  sparks  which  the  coil  is  designed  to  deliver.  For 
a  coil  of  10-  or  12-inch  spark  length  the  rubber  tube  is  ordinarily 
f  of  an  inch  thick.  For  the  larger  coils  it  may  be  two  or  three 
times  as  thick.  Insulating  tubes  of  micanite,  a  mixture  of 
mica  and  shellac,  have  been  employed  instead  of  hard  rubber. 
These  micanite  tubes  are  perhaps  a  little  less  liable  to  be  punc- 
tured by  sparks  than  those  of  hard  rubber.  Some  makers 
do  not  employ  an  insulating  tube  between  the  primary  and 
secondary,  but  depend  for  this  insulation  upon  the  wax  or 
other  insulating  material  in  which  the  secondary  is  imbedded. 
Insulation  of  the  Secondary  Winding. — In  the  better  coils 
the  secondary  is  wound  in  a  large  number  of  vertical  sections 
which  are  separated  from  each  other  by  washers  of  paper  or 
fiber.  These  sections  are  really. flat  helices,  usually  about  i 

k  t, 

of  an  inch  long,  and  in  a  10-  or  12-inch  coil  there  may  be  as 
many  as  80  or  100  of  them  connected  up  in  series. 

In  order  to  prevent  discharges  between  the  sections  of  the 
secondary  winding  it  is  necessary  that  they  should  be  imbedded 
in  some  good  insulating  material.  In  most  coils  they  are 
imbedded  in  a  solid  mass  of  wax.  Some  makers  use  oil  for 
this  insulation,  and  immerse  the  whole  induction  coil  in  a 
tank  containing  some  heavy  petroleum  oil.  The  wax  is  to  a 
certain  extent  liable  to  crack  owing  to  changes  of  temperature, 
and  the  oil  is  very  dirty  and  very  liable  to  leak  and  cause 
trouble.  In  order  to  avoid  these  difficulties,  some  makers  have 
imbedded  coils  in  a  viscous  substance  which  does  not  become 
hard  enough  to  be  brittle,  nor  soft  enough  to  flow,  as  does 
the  oil.  If  a  wax  which  has  a  very  small  temperature  co- 
efficient of  expansion  is  used,  the  liability  to  cracking  is  very 
small,  and  on  account  of  the  greater  cleanliness  and  convenience 
of  the  wax  insulation  it  has  been  adopted  by  most  makers. 
A  few  coils  have  been  made  with  the  sections  of  the  secondary 
separated  by  insulating  washers  of  vulcanite  or  glass,  and 
spaced  far  enough  apart  so  that  the  insulation  afforded  by 
the  air  is  sufficient  to  prevent  the  sparks  from  passing  between 
them.  This  construction  has  the  advantage  of  allowing  a 
burnt-out  section  to  be  readily  replaced,  but  it  has  the  great 
disadvantage  of  offering  free  access  to  moisture,  which  is 


BREAKDOWN   IN   COILS.  63 

almost  certain  to  collect  and  eventually  impair  the  insulation 
between  the  windings.  The  wax  insulated  coils  of  the  best 
makers  are  usually  so  satisfactory  that  there  is  no  excuse 
for  such  a  makeshift  as  this. 

Insulation  of  the  Secondary  Terminals. — In  some  coils  the 
ends  of  the  secondary  wire  are  brought  out  and  connected 
with  metal  binding  posts  which  are  attached  to  the  wooden 
framework  of  the  coil.  This  is  bad  construction,  especially  for 
the  larger  coils,  which  are  occasionally  subjected  to  the  un- 
necessary strain  of  giving  15-  or  20-inch  sparks.  In  almost 
every  kind  of  wood  there  is  a  certain  amount  of  leakage,  and 
when  it  is  subjected  to  high  potentials  in  a  damp  atmosphere 
there  may  be  enough  moisture  present  in  the  wood  so  that 
this  leakage  will  seriously  impair  the  output  of  the  coil.  The 
better  coils  have  the  secondary  terminals  brought  out  through 
insulating  sleeves  to  terminals  supported  on  hard-rubber  posts. 

Breakdowns  in  Coils. — In  order  to  secure  efficiency  in  an 
induction  coil  it  is  necessary  to  bring  the  secondary  winding 
as  close  as  possible  to  the  primary  and  core.  In  practice  the 
distance  between  the  ends  of  the  secondary  windings  and 
the  nearest  parts  of  the  primary  and  core  is  very  much  less 
than  the  sparking  distance  of  the  coil  through  the  air,  and 
the  sparks  are  only  >  prevented  from  taking  the  shorter  path 
through  the  primary  by  the  fact  that  the  solid  wax  and  rubber 
insulation  offers  very  much  more  obstruction  to  them  than 
the  air. 

The  most  common  cause  of  breakdown  of  the  induction 
coil  is  failure  of  the  insulation  between  the  primary  and 
secondary  windings,  or  between  the  adjacent  sections  of  the 
secondary.  When  the  spark  passes  through  the  wax  or 
rubber  insulation,  the  material  is  carbonized,  so  that  its  insu- 
lating properties  are  destroyed  and  the  coil  cannot  deliver 
long  sparks.  These  breakdowns  are  liable  to  occur  when  the 
insulation  is  unduly  strained  by  causing  the  coil  to  deliver 
very  long  sparks,  and  when  the  coil  has  become  overheated 
and  the  dielectric  strength  of  the  insulating  material  thereby 
reduced.  Another  cause  of  breakdown  is  in  the  cracking 
of  the  wax  due  to  unequal  expansion  or  imperfection  in  con- 


64  INDUCTION   COILS   AXD    INTERRUPTERS. 

struction.  Sometimes  in  the  winding  there  may  be  a  short 
circuit  between  the  different  portions  of  the  secondary.  When 
this  occurs,  the  current  which  circulates  in  the  short-circuited 
portion  not  only  reduces  the  output  of  the  coil,  but  it  is  almost 
certain  to  cause  considerable  heating  at  this  point,  and  render 
a  puncture  of  the  insulation  easy.  Sometimes  when  the  wires 
from  the  terminals  of  the  coil  to  the  tube  are  allowed  to  lie 
across  the  cover  of  the  coil,  a  spark  will  pass  between  it  and 
the  wires  underneath.  This  is  not  so  serious  as  a  puncture 
of  the  insulating  tube,  or  a  short-circuit  of  the  secondary  wind- 
ings, but  it  should,  of  course,  be  avoided. 

The  coils  of  the  best  makers  are  carefully  tested  before 
they  are  sent  out,  and  if  they  are  not  subjected  to  bad  usage 
they  usually  work  satisfactorily  for  a  number  of  years  without 
repair. 

In  order  to  avoid  breakdowns  of  the  insulation  it  is  well 
not  to  force  the  coil  to  deliver  unnecessarily  long  sparks,  and 
to  be  careful  that  the  wires  connecting  the  secondary  and 
the  tube  do  not  come  within  sparking  distance  of  the  core, 
primary,  or  ground  wire.  In  order  to  lessen  strains  on  the 
insulation  which  may  occur  in  case  of  grounding  one  terminal 
of  the  secondary,  some  makers  connect  the  middle  of  the  secon- 
dary winding  to  the  primary. 

Requirements  of  an  Induction  Coil  for  X-ray  Work. — It  was 
shown  in  a  preceding  chapter  that  for  operating  Crookes  tubes 
for  practical  fluoroscopic  and  radiographic  work  potentials 
such  as  would  produce  sparks  1^  to  6  or  7  inches  long  are 
needed.  It  is  safe  to  say  that  the  whole  range  of  tubes  which 
are  required  in  practice  does  not  require  a  greater  potential 
than  that  necessary  to  produce  a  spark  through  8  inches  of  air. 
If  we  allow  2  inches  for  series  spark  gaps  to  cut  off  the  inverse 
discharge,  the  maximum  spark  length  necessary  in  a  coil  for 
practical  x-ray  work  will  be  not  more  than  10  inches.  In 
order  to  produce  the  powerful  x-rays  that  are  necessary  for 
rapid  radiographic  work  it  will  be  necessary  that  the  coil  shall 
deliver  a  very  powerful  discharge  at  such  spark  length. 

When  the  sparks  from  a  coil  appear  thin  and  blue,  the  amount 
of  energy  represented  is  small.  The  coil  for  rapid  radiographic 


INTERRUPTERS.  65 

work  should  deliver  thick  yellow  sparks,  which  have  been 
called  "fat,"  or  "fuzzy,"  in  contradistinction  to  the  thin, 
wiry,  crackling  spark  produced  by  discharges  of  small  amount 
of  energy.  Unfortunately  manufacturers  of  coils  have  given 
more  attention  to  the  length  of  the  spark  produced  than  to 
the  amount  of  energy  that  may  be  obtained  from  them  at 
potentials  suitable  for  operating  x-ray  tubes. 

The  ordinary  8-inch  coils  easily  deliver  sparks  8  inches  long, 
but  do  not  deliver  sufficient  energy  to  get  the  best  results 
from  a  Crookes  tube.  In  the  present  state  of  affairs  one  must 
buy  a  coil  which  is  rated  at  from  12  to  18  inches  in  order  to 
obtain  one  which  will  deliver  a  6-inch  spark  of  sufficient  volume 
for  rapid  radiographic  work.  Some  z-ray  workers  have  thought 
it  necessary  to  use  even  larger  coils,  and  have  procured  appa- 
ratus giving  sparks  of  25  to  40  inches  in  length.  The  manu- 
facture of  a  coil  which  will  deliver  a  spark  40  inches  in  length 
is  a  difficult  matter,  because  of  the  extraordinary  amount 
of  insulation  which  is  needed  for  such  discharges,  and  which 
is  quite  unnecessary  if  the  coil  is  to  be  used  for  operating  x-ray 
tubes.  The  expense  of  constructing  large  induction  coils  in- 
creases in  a  much  faster  ratio  than  the  length  of  spark  delivered, 
and  the  size  and  weight  are  also  out  of  proportion  with  the 
increase  of  spark  length.  It  is  manifestly  absurd  to  build 
induction  coils  to  deliver  sparks  20  to  40  inches  in  length  for 
use  with  Crookes  tubes  which  ordinarily  do  not  demand  a 
greater  potential  than  that  represented  by  sparks  2  to  5  or 
6  inches  in  length. 

It  has  not  yet  been  definitely  determined  whether  as  strong 
rays  are  necessary  for  therapeutic  uses  as  are  desirable  in 
radiographic  work,  but  at  present  it  seems  that  an  ordinary 
coil  of  6  or  8  inches  spark  length  will  deliver  sufficient 
energy  in  most  cases.  For  radiographic  work,  however,  it  will 
be  safer  to  employ  a  coil  which  is  rated  at  15  to  18  inches  spark 
length. 

Interrupters. — Differences  of  potentials  in  the  terminals  of 
the  secondary  winding  of  the  coil  are  produced  whenever 
there  is  a  change  in  the  strength  of  the  primary  current;  and 
the  more  rapid  the  rate  of  change  in  the  primary  current,  the 

5 


66  INDUCTION    COILS   AND    INTERRUPTERS. 

greater  will  be  the  difference  of  potential  at  the  secondary 
terminal.  When  the  primary  current  is  increasing  in  strength, 
the  secondary  current  will  be  in  the  direction  opposite  to  that 
which  is  produced  when  the  primary  current  is  decreasing  in 
strength. 

The  function  of  the  interrupter  is  to  break  the  primary 
current  very  suddenly  so  that  this  decrease  in  strength  will 
be  as  rapid  as  possible.  The  increase  in  the  strength  of  the 
primary  current  when  the  circuit  is  closed  can  never  be  nearly 
so  rapid  as  its  decrease  when  the  circuit  is  opened.  It  is  de- 
sirable that  the  primary  current  shall  increase  rapidly  enough 
so  that  the  core  may  be  fully  magnetized  a  great  many  times 
per  second;  but  the  increase  should  not  be  so  rapid  that 
the  inverse  discharge  produced  by  it  will  be  of  high  po- 
tential. 

The  secondary  discharge  at  the  break  of  the  primary  current 
is  the  one  which  is  useful  for  operating  :r-ray  tubes.  The 
discharge  at  the  make  is  in  the  inverse  direction,  and  tends 
to  have  an  undesirable  effect  upon  a  tube,  impairing  its  vacuum, 
and  introducing  sources  of  x-ray  at  other  points  than  the 
focus  of  the  cathode  upon  the  target.  It  is,  of  course,  desirable 
that  the  secondary  discharges  through  the  tube  shall  be  as 
frequent  as  possible,  and  it  is  therefore  desirable  that  the 
interrupter  shall  be  capable  of  breaking  the  primary  current 
a  large  number  of  times  per  second,  but  that  the  rise  of  the 
current-strength  when  the  primary  circuit  is  closed  shall  not 
be  rapid  enough  to  cause  strong  inverse  discharges.  The 
closure  of  the  primary  circuit  in  all  interrupters  is  practically 
instantaneous,  and  the  rise  of  the  current-strength  in  the 
primary  depends  upon  the  potential  of  the  exciting  circuit, 
and  upon  the  winding  of  the  coil.  A  high  potential  in  the 
exciting  current  tends  to  make  this  rise  more  rapid,  and  in 
a  coil  of  a  small  number  of  turns  in  the  primary  the  current 
will  rise  more  rapidly  than  in  one  which  has  a  large  number 
of  turns.  The  undesirable  inverse  discharge  will  therefore  be 
less  with  a  coil  having  a  large  number  of  turns  in  the  primary, 
but  with  such  a  coil  the  time  required  for  magnetizing  the 
core  will  be  somewhat  longer,  and  it  will  therefore  be  impossible 


VIBRATING    INTERRUPTERS.  67 

to  obtain  in  a  given  time  as  many  full  discharges  as  with  a 
coil  of  a  few  turns  in  the  primary.  The  difficult  problem  in 
interrupters  is  to  secure  a  perfectly  sudden  break  of  the  primary 
current.  Electrical  circuits  have  a  property  which  is  somewhat 
like  inertia,  and  which  tends  to  prevent  a  sudden  stoppage 
of  the  current  flowing  through  them.  When  the  contacts 
of  the  interrupter  are  separated,  this  tendency  for  the  current 
to  continue  is  liable  to  cause  an  arc  to  pass  between  the  separated 
points.  When  this  occurs,  the  current  does  not  fall  suddenly 
from  its  maximum.  No  interrupter  for  induction  coils  has 
yet  been  devised  which  is  in  all  respects  satisfactory. 

There  are  many  different  forms  of  interrupters  in  use,  and 
they  may  be  conveniently  divided  into  three  classes:  First, 
those  in  which  the  interruption  is  produced  by  the  separation 
of  two  solid  pieces  of  metal  which  are  in  contact ;  second,  those 
in  which  the  interruption  takes  place  between  mercury  and  a 
solid  metal  contact;  and,  third,  electrolytic  interrupters,  in 
which  the  break  takes  place  between  two  electrolytic  con- 
ductors or  between  an  electrolyte  and  a  metallic  conductor. 

The  first  class  includes  the  vibrating  interrupters  and  rotary 
interrupters  in  which  the  break  takes  place  between  a  metallic 
contact  wheel  and  a  brush  bearing  upon  it. 

Vibrating  Interrupters. — One  of  the  simplest  forms  of  vibrating 
interrupter  is  that  of  Apps,  which  is  shown  in  figure  26.  The 
principle  of  its  operation  is  practically  the  same  as  that  of 
the  vibrating  hammer  in  an  electric  bell.  The  primary  current 
is  led  through  two  platinum  contact  points,  c,  E,  one  of  which  is 
attached  to  a  spring,  s,  carrying  an  armature  of  soft  iron.  This 
armature  is  arranged  opposite  the  end  of  the  core  of  the  in- 
duction coil.  When  the  current  flows  through  the  primary 
coil,  the  core  becomes  magnetic,  attracts  the  armature,  and 
pulls  the  contact  attached  to  the  spring  away  from  the  fixed 
contact,  E,  thus  breaking  the  circuit.  As  soon  as  the  circuit  is 
broken  the  core  demagnetizes,  and  the  spring  carrying  the 
armature  contact  makes  contact  again  with  the  fixed  point. 
The  tension  of  the  spring  which  carries  the  armature  contact 
point  may  be  adjusted  by  means  of  a  thumb-screw,  T.  This 
interrupter  is  very  simple  and  reliable  for  coils  of  moderate 


68 


INDUCTION    COILS    AND    INTERRUPTERS. 


size,  and  is  preferred  to  all  others  for  operating  coils  for  wire- 
less telegraphy. 

In  another  form  of  vibrating  interrupter  shown  in  diagram 
in  figure  27  the  movable  contact  is  attached  to  a  separate 
spring.  The  spring  carrying  the  armature  is  provided  with 
a  hook  arrangement  which  engages  the  contact  spring  and 
pulls  the  movable  contact  away  from  the  one  which  is  fixed 
after  the  armature  has  moved  through  a  certain  distance  and 
has  attained  considerable  velocity. 

This  type  of  interrupter  has  the  advantage  that  the  separation 


Fig.  26. — Apps'  vibrating  interrupter. 

of  the  contacts  is  not  made  until  the  armature  has  attained 
considerable  velocity,  and  is  therefore  somewhat  quicker  than 
in  the  simpler  forms,  like  that  of  Apps.  Vibrating  interrupters 
embodying  this  idea  are  sold  under  many  names,  as  the  Yril 
break,  hammer  break,  etc. 

Both  of  these  interrupters  are  operated  by  the  magnetism  of 
the  core  of  an  induction  coil,  and  their  operation  will  therefore 
be  affected  by  changes  in  the  strength  of  the  exciting  current 
of  the  coil.  In  order  to  avoid  this  difficulty,  a  number  of 
makers  have  provided  a  separate  magnet,  operated  by  an 


VIBRATING    INTERRUPTERS. 


69 


independent  circuit,  so  that  the  operation  will  be  independent 
of  the  strength  of  the  primary  current  used.  These  interrupters 
nearly  all  embody  the  principle  of  the  Vril  or  hammer  break. 
The  best  vibrating  interrupters  have  a  considerable  range  in 
adjustment,  and  are  fairly  satisfactory  for  use  with  coils  for 
radiographic  work.  With  the  smaller  coils  they  are,  per- 
haps, as  satisfactory  as  any  type  of  interrupter.  They  all 
have  a  number  of  inherent  difficulties.  They  are  more  or 
less  noisy,  the  contact  springs  are  liable  to  break,  the 
platinum  points  wear  un- 
evenly, giving  rise  to  im- 
perfect contact,  and  the 
heating  at  the  platinum 
contact  points  may  be  suf- 
ficient to  cause  an  incipi- 
ent welding  or  sticking  of 
the  points  together,  so 
that  the  pull  of  the  mag- 
net does  not  separate 
them.  When  this  occurs, 
the  primary  current  is  not 
interrupted,  and  it  is 
liable  to  become  unduly 
strong,  to  burn  out  fuses, 
and  in  other  ways  make 
trouble. 

On  account  of  the  sim- 

.  Fig.  27. — Diagram  of  Vril  vibrating 

pllClty   of  these   interrupt-  interrupter. 

ers,    their    small    weight, 

and  the  comparatively  small  space  required  for  them,  they  are 
very  useful  in  a  number  of  situations.  In  portable  apparatus 
they  are  almost  indispensable. 

In  operating  interrupters  of  this  type  it  is  necessary  to  adjust 
the  contact  points  so  that  the  vibrations  of  the  armature  are 
strong  and  even.  The  rapidity  of  the  interruptions  may  be 
varied  somewhat  in  some  of  the  types  by  changing  the  amount 
of  weight  on  the  vibrating  spring,  thus  changing  its  natural 
period  of  vibration.  For  radiographic  work  it  will  usually  be 


70  INDUCTION    COILS   AND    INTERRUPTERS. 

better  to  run  such  a  vibrator  at  its  lowest  speed.  The  contact 
points  must  be  adjusted  so  as  to  reduce  as  much  as  possible 
the  sparking  which  occurs  at  the  break,  and  they  must  be 
kept  clean,  bright,  and  even.  A  very  small,  thin  file  will  be 
convenient  for  evening  up  the  contact  surfaces  of  these 
platinum  points.  If  the  interrupter  sticks  or  stops  vibrating, 
the  primary  circuit  should  be  opened  at  the  switch  to  prevent 
damage  by  excessive  flow  of  current. 

With  the  independent  multiple  vibrators  the  circuit  which 
operates  the  vibrator  magnet  must  be  closed  before  the  induction 
coil  circuit  is  closed,  and  it  will  usually  be  necessary  to  put 
the  armature  in  vibration  by  snapping  it  with  the  finger. 

Rotary  Interrupters. — Interrupters  in  which  the  separation  of 
the  contacts  is  effected  by  a  movement  of  rotation  (usually 
produced  by  an  electric  motor)  are  more  positive  in  their 
action  than  the  vibrating  interrupters.  In  the  vibrating  inter- 
rupters the  tendency  to  spark  at  the  break  is  reduced  by  the 
use  of  platinum  contact  points,  but. in  the  rotary  breaks  the 
contact  pieces  are  so  large  that  it  is  not  feasible  to  make  them 
of  platinum.  They  are  usually  made  of  brass  and  copper, 
and  these  metals  have  a  tendency  to  flash  or  form  arcs  at  the 
break,  and  thus  fail  to  suddenly  stop  the  current. 

In  order  to  prevent  this  arcing,  some  of  these  rotary  inter- 
rupters have  the  contact  wheel  and  brush  immersed  in  oil. 
I  have  used  for  a  number  of  years  a  rotary  interrupter  in  which 
the  sparking  at  the  break  is  prevented  by  a  packing  of  asbestos 
attached  to  the  metal  brush  and  filling  up  the  space  in  which 
the  arc  would  otherwise  occur.  This  interrupter  works  very 
satisfactorily  with  current  strengths  up  to  4  or  5  amperes 
from  the  110- volt  lighting  circuit.  "With  strong  currents,  how- 
ever, this  flashing  at  the  break  occurs  even  with  the  asbestos 
packing,  and  the  action  is  not  satisfactory.  By  making  the 
contact  wheel  and  brushes  of  certain  alloys  known  as  non-arcing 
metals  the  tendency  to  spark  at  the  break  is  somewhat  reduced. 
Most  of  the  rotary  breaks  have  not  been  satisfactory,  and 
nearly  all  makers  in  this  country  have  discarded  them. 

One  of  the  German  types  of  rotary  interrupter  which  works 
in  oil  is  shown  in  figure  28.  In  this  apparatus  the  non-arcing 


ROTARY    INTERRUPTERS. 


71 


material  is  mercury  amalgam  of  copper,  the  mercury  being 
constantly  supplied  to  keep  the  surface  bright  and  well  amal- 
gamated. 

H 


Fig.  28.—  Hirschmann's  rotary  interrupter. 

One  of  the  best  of  the  rotary  interrupters  is  the  one  designed 
by  Contremoulin,  and  made  by  Gaiffe  &  Co.,  Paris.  This  is 
really  nothing  more  than  a  rotating  contact  wheel  with  brushes 


72 


INDUCTION    COILS    AND    INTERRUPTERS. 


operating  under  oil.  One  of  the  brushes  is  arranged  so  that 
by  adjusting  its  position  the  relative  duration  of  make  and 
break  of  the  primary  current  may  be  varied.  If  the  range 
of  this  variation  is  sufficiently  wide,  no  rheostat  is  required 
and  the  output  of  the  coil  may  be  reduced  from  the  maximum 
to  the  minimum  by  simply  changing  the  relative  period  of 
the  make  and  break.  This  method  of  regulation  is  shown  in 
diagram  in  figure  29.  The  current  is  led  through  the  interrupter 
from  one  brush  to  the  other,  and  the  two  metallic  segments 
of  the  wheel  are  connected  together.  It  is  therefore  necessary 
that  both  brushes  be  in  contact  with  metallic  segments  in  order 
that  the.  current  may  pass.  If  the  regulating  brush  is  in  the 
position  shown  at  A,  both  brushes  will  come  in  contact  with 

the  metallic  segments  at 
-~  C  the  same  time,  and  the 

/'/      ^^  current  will  flow  through 

//  \  the  coil  for  a  maximum 

length  of  time.  If  the 
brush  A  is  shifted  to 
the  position  shown  by 
the  dotted  line  B,  both 
brushes  will  be  in  simul- 
taneous contact  with 
the  metallic  segments 
during  a  very  much 
smaller  part  of  the 
revolution  of  the  wheel; 

and  if  the  regulating  brush  is  carried  to  the  point  shown  at  c, 
the  two  brushes  will  never  be  both  in  contact  with  metallic 
segments  at  the  same  time,  therefore  no  current  will  flow 
through  the  coil.  Although  these  interrupters  have  not  been 
used  to  any  extent,  it  is  but  fair  to  say  that  they  are  probably 
quite  as  efficient  as  the  mercury  turbine  breaks,  although  they 
have  not  been  made  to  give  the  same  frequency  of  interruption. 
With  the  coils  which  have  a  large  number  of  turns  in  the 
primary  winding,  and  which  therefore  do  not  require  very 
strong  exciting  currents,  these  rotary  interrupters  are  to  my 
mind  the  best  kind  for  use  with  the  110-volt  direct-current 


Fig.  29. — Diagram  showing  method  of  regula- 
tion in  Contremoulin's  interrupter. 


MERCURY    INTERRUPTERS. 


73 


circuit.  In  nearly  all  induction  coils,  however,  the  primary 
winding  is  such  that  it  is  necessary  to  use  strong  exciting  cur- 
rents, and  with  such  coils  these  interrupters  are  not  so  satis- 
factory. 

Mercury  Interrupters. — The  use  of  mercury  in  interrupters 
has  two  advantages.  Owing  to  the  fact  that  the  metal  is  a 
liquid,  it  makes  very  perfect  contact;  and  owing  to  the  fact 
that  its  vapor  has  exceedingly  high  resistance,  the  tendency 
to  spark  when  the  contact  is  broken  is  very  much  less  than 
with  many  other  metals. 


Fig.  30. — Mercury  "plunger"  interrupter  with  tachometer  for  indicating  the 
frequency  of  interruption. 

The  mercury  interrupters  in  common  use  are  of  two  kinds. 
In  one  type  the  circuit  is  closed  and  opened  by  a  metallic  con- 
ductor which  makes  and  breaks  contact  with  the  mercury  by 
rapidly  dipping  below  its  surface  and  out  again.  In  order  to 
lessen  the  spark  at  the  break,  and  to  prevent  the  mercury 
vapor  from  reaching  the  air,  a  layer  of  oil  or  alcohol  is  usually 
floated  on  top  of  the  mercury.  This  interrupter  is  usually 
operated  by  a  small  electric  motor,  and  the  frequency  of  the 
interruptions  is  varied  by  regulating  the  speed  of  the  motor 
by  means  of  a  small  rheostat.  The  relative  period  of  make 


74  INDUCTION    COILS    AND    INTERRUPTERS. 

and  break  is  susceptible  to  some  adjustment  by  raising  or 
lowering  the  mercury  cup.  Obviously,  the  higher  the  level  of 
the  mercury,  the  longer  will  be  the  duration  of  contact  with 
the  moving  conductor. 

In  one  form  of  mercury  dip  interrupter  the  moving  contact 
piece  consists  of  a  wire  plunger  which  is  connected  by  a  crank 
on  the  shaft  of  an  electric  motor  caused  to  oscillate  rapidly 
up  and  down  and  to  dip  in  and  out  of  the  mercury.  Inter- 
rupters of  this  general  type  are  made  by  most  of  the  German 
manufacturers  of  :r-ray  apparatus.  One  of  Max  Kohl's  mer- 


Fig.  31. — Mackenzie  Davidson  mercury  interrupter. 

cury  plunger  interrupters,  as  they  are  called,  is  shown  in  figure 
30. 

Dr.  James  Mackenzie  Davidson  has  designed  a  mercury  dip 
interrupter  in  which  the  moving  contact  piece  is  rigidly  at- 
tached to  the  shaft  of  a  motor  which  gives  it  a  rotary  motion. 
The  motor  shaft  is  inclined  at  an  angle  so  that  during  part  of  its 
revolution  the  contact  arm  dips  into  the  mercury.  This  inter- 
rupter is  much  simpler  in  construction  than  the  plunger  type, 
and  runs  much  more  quietly,  owing  to  the  fact  that  there  is 
no  reciprocating  motion.  The  general  appearance  of  it  is 
shown  in  fijnire  31. 


TURBINE    INTERRUPTERS. 


75 


Turbine  Interrupters. — In  the  turbine  interrupters  the  closing 
and  opening  of  the  circuit  of  the  coil  is  effected  by  a  stream 
of  mercury  which  is  caused  to  play  against  a  series  of  toothed 
metal  conductors.  Interrupters  embodying  this  principle  are 
made  by  several  manufacturers  of  x-ray  apparatus.  In  all 
of  them  there  is  a  reservoir  containing  mercury,  and  a  spiral 
screw-pump  which  raises  the  mercury  from  the  reservoir,  and 
allows  it  to  flow  through  a  nozzle  against  the  metal  vanes. 
In  most  of  these  instruments  the  position  of  the  mercury  jet 
is  fixed,  and  the  interruption  is  effected  by  rotating  the  toothed 
metal  conductors  against 
which  the  stream  impinges. 
These  teeth  or  vanes  are  tri- 
angular in  shape  with  the 
points  projecting  downward, 
and  by  raising  or  lowering 
the  mercury  jet  the  duration 
of  the  contact  between  the 
mercury  and  metal  vanes 
may  be  A^aried.  In  this  way 
a  considerable  range  of  regu- 
lation of  the  coil  may  be 
effected. 

The  turbine  interrupters  of 
the  various  makers  differ 
only  in  unessential  points 
of  mechanical  construction. 
The  one  of  Dr.  Max  Levy  is 
shown  in  figure  32,  and  its  construction  is  practically  identical 
with  that  of  the  other  German  turbine  interrupters.  In  all  of 
these  the  break  takes  place  in  oil.  For  use  with  direct  current 
circuits  the  turbine  interrupter  is  belted  to  a  small  direct  cur- 
rent motor  the  speed  of  which  may  be  varied  by  a  small  rheostat 
and  thus  give  different  frequency  of  interruption. 

When  used  with  alternating  current,  the  interruptions  must 
always  occur  at  a  definite  phase  of  the  current  wave,  and  the 
speed  must  therefore  bear  a  fixed  ratio  to  the  frequency  of 
the  alternations  of  the  current.  This  is  accomplished  by  a 


Fig.  32. — Levy's  mercury  jet 
interrupter. 


76 


INDUCTION    COILS    AND    INTERRUPTERS. 


synchronous  alternating  current  motor.  Synchronous  motors 
are  not  self-starting  and  when  used  for  this  purpose  they  are 
provided  with  a  gear-wheel  and  crank  by  means  of  which 
they  may  be  run  up  to  full  speed  by  hand  at  starting.  These 
interrupters  are  arranged  with  an  adjustment  by  which  the 
interruptions  may  be  produced  at  any  desired  period  of  the 
alternating  current  wave,  which  is,  of  course,  constantly  varying 
in  strength.  In  this  way  a  wide  range  of  regulations  may  be 

obtained  and  no  rheo- 
stat is  necessary.  The 
appearance  of  one  of 
these  interrupters  is 
shown  in  figure  33. 

In  Dr.  Cunningham's 
modification  of  the  tur- 
bine interrupter  the  me- 
tallic vanes  are  fixed 
and  the  nozzle  through 
which  the  mercury 
issues  is  rotated.  The 
adjustment  of  the  rela- 
tive duration  of  make 
and  break  is  effected 
by  raising  and  lowering 
the  vanes.  The  mer- 
cury stream  is  divided 
into  two  jets,  and  the 
contact  is  broken  at  two 
points  instead  of  one, 
as  in  the  other  forms. 
Cunningham  prefers  not 

to  use  oil,  but  provides  the  rotating  nozzle  with  an  air-blast 
which  is  intended  to  blow  out  the  sparks  produced  at  the  break. 
This  interrupter  is  shown  in  figure  34. 

In  all  mercury  interrupters  the  mercury  gradually  disappears, 
and  there  is  formed  on  the  surface  a  scum  which  is  made  up 
of  impurities  and  finely  powdered  mercury.  In  those  types 
in  which  the  break  occurs  in  oil,  the  mercury  vapor  which  is 


Fig.  33. — Mercury  jet  interrupter  with 
synchronous  motor  for  use  with  alternating 
currents. 


TURBINE   INTERRUPTERS. 


77 


produced  at  every  interruption  condenses  and  remains  in 
suspension  in  the  oil,  forming  a  mud  which  settles  over  the 
surface  of  the  mercury.  In  the  plunger  types  this  scum 
interferes  with  the  contact  between  plunger  and  mercury. 
In  some  of  the  turbine  interrupters  in  which  oil  is  used  the 
rapid  rotary  motion  causes  the  oil  to  be  sprayed  out  and  damage 
furniture,  carpets,  etc.  Sometimes  the  oil  is  vaporized  and 
forms  an  explosive  mixture  with  the  air,  and  an  explosion 


Fig.  34. — Cunningham's  mercury  jet  interrupter. 

may  occur.  This  accident,  however,  is  very  rare,  and  is 
not  liable  to  occur  if  care  is  taken  to  see  that  the  interrupter 
does  not  become  too  hot,  and  that  the  level  of  the  oil  is  suffi- 
ciently high.  When  the  break  occurs  in  the  air,  there  is  always 
a  risk  of  the  poisonous  mercury  vapor  escaping  into  the  room. 
The  mercury  becomes  broken  up  into  a  fine  powder  which 
settles  as  flour  on  the  surface,  and  which  after  a  time  interferes 


78  INDUCTION    COILS    AND    INTERRUPTERS. 

with  the  action  of  the  instrument.  In  all  of  these  interrupters, 
then,  it  will  be  necessary  to  clean  the  mercury  from  time  to 
time,  and  to  keep  adding  a  little  more  in  order  that  the  total 
quantity  does  not  become  reduced.  With  most  of  them  it 
will  also  be  necessary  to  replace  the  oil.  In  practice  these 
interrupters  require  cleaning  and  adjusting  about  once  a  month, 
and  except  for  this  they  require  a  very  small  amount  of  atten- 
tion. It  is  therefore  quite  advisable  to  put  such  an  interrupter 
in  another  room  or  a  cellar  at  a  distance  from  the  induction 
coil  to  which  it  may  be  connected  by  a  pair  of  wires. 

In  some  respects  these  interrupters  are  more  satisfactory 
than  any  other  for  general  work.  They  give  rapid  rate  of 
interruption,  which  may,  of  course,  be  varied  within  certain 
limits  by  changing  the  speed  of  the  motor.  In  the  turbine 
interrupters  if  the  motor  speed  falls  below  a  certain  point, 
the  rotary  pump  fails  to  lift  the  mercury  high  enough  to  produce 
the  jet,  and  the  circuit  is  not  closed.  This  feature  is  really 
an  element  of  safety,  for  no  current  can  pass  through  the  inter- 
rupter when  it  is  at  rest,  and  thus  there  is  no  danger  in  closing 
the  induction  coil  switch  before  the  interrupter  is  started.  In 
case  of  an  accident  which  stops  the  motor  the  circuit  will  remain 
open  at  the  interrupter  as  soon  as  the  speed  falls  below  the 
critical  point. 

For  radiographic  work  most  coils  operate  more  satisfactorily 
at  a  comparatively  slow  frequency  of  interruption,  which  gives 
exceedingly  strong  heavy  sparks.  For  this  work  the  mercury 
dip  interrupter  is  better  than  the  turbine  interrupters  as  they 
are  usually  constructed.  On  account  of  the  high  frequency 
of  interruptions  which  may  be  obtained  with  the  turbine  in- 
terrupters they  give  a  very  steady  illumination  of  the  fluores- 
cent screen  for  fluoroscopic  work. 

Electrolytic  Interrupters. — A  great  many  years  ago  it  was 
noticed  by  Spottiswoode,  Plante,  and  others  that  if  a  strong 
electrical  current  were  passed  through  an  electrolyte  by 
means  of  two  electrodes,  one  of  which  had  a  comparatively 
small  area,  the  current  would  be  interrupted  by  the  collec- 
tion of  non-conducting  gases  over  the  small  electrode.  This 
action  was  studied  very  carefully  by  Paul  Hoho,  and  was  de- 


ELECTROLYTIC  INTERRUPTERS.  79 

scribed  in  detail  by  him  in  La  Lumiere  Electrique,  February, 
1894. 

The  interrupting  action  is  clue  to  a  film  of  non-conducting 
gas  or  vapor  forming  around  the  small  electrode.  The  forma- 
tion of  this  gas  is  apparently  due  partly  to  the  vaporization 
of  the  liquid,  and  partly  to  electrolytic  decomposition. 

Although  these  phenomena  were  known  long  ago,  the  prin- 
ciple was  apparently  not  applied  to  interrupters  for  induction 
coils  until  1899,  when  Professor  A.  Wehnelt,  of  Charlottenburg, 
published  a  description  of  his  interrupter.  Wehnelt 's  inter- 
rupter consists  of  a  jar  of  dilute  sulphuric  acid  in  which  is 
immersed  a  lead  electrode  of  considerable  surface,  and  a  small 
electrode  made  of  a  platinum  wire  sealed  into  the  end  of  a 
glass  tube  and  connected  with  the  leading-in  wire  by  means 
of  a  little  mercury  poured  into  the  tube.  When  this  arrange- 
ment is  connected  in  series  with  an  induction  coil,  and  the 
current  is  caused  to  flow  in  such  a  direction  that  hydrogen 
is  produced  at  the  platinum  electrode,  very  rapid  interruptions 
of  the  current  are  produced,  and  powerful  secondary  discharges 
may  be  obtained  from  the  coil.  The  details  of  this  interrupting 
action  are  not  fully  understood,  but  it  is  certain  that  the  in- 
ductance of  the  electrical  circuit  plays  an  important  part 
in  it. 

With  a  Wehnelt  interrupter  the  interruption  occurs  in  prac- 
tice only  when  the  platinum  electrode  is  made  the  negative 
pole.  If  the  current  is  sent  through  it  in  the  opposite  direction, 
interruptions  may,  under  certain  conditions,  be  obtained,  but 
the  platinum  will  be  very  rapidly  destroyed.  Sometimes  after 
a  few  minutes'  use  this  interrupter  may  stop  because  of  a 
bubble  of  gas  which  collects  over  the  platinum  electrode  and 
prevents  the  liquid  from  making  contact  with  it.  The  bubble 
may  be  removed  by  shaking  the  electrode,  or  by  reversing 
the  direction  of  the  current  for  an  instant,  and  the  operation 
will  commence  again.  If  the  interrupter  has  been  in  action 
for  some  time,  the  liquid  becomes  hot,  and  the  interrupting 
action  becomes  unsteady  and  sometimes  stops.  It  has  been 
proposed  to  keep  the  liquid  cool  by  immersing  in  it  a  coil  of 
lead  pipe  through  which  cold  water  may  be  circulated.  In 


80  INDUCTION    COILS   AND    INTERRUPTERS. 

practice  it  is  better  to  use  a  large  jar  containing  such  an  amount 
of  liquid  that  the  rise  of  temperature  is  slow,  and  having  such 
a  large  surface  exposed  that  the  loss  of  heat  from  the  liquid 
is  facilitated.  In  the  operation  of  this  interrupter  certain 
insoluble  lead  salts  may  be  formed  from  the  lead  electrode, 
and  by  remaining  in  suspension  in  the  liquid  interfere  somewhat 
with  the  action  of  the  instrument. 

The  fact  that  with  this  interrupter  the  interruptions  occur 
ordinarily  only  when  the  platinum  electrode  is  made  the  cathode 
makes  it  possible  to  employ  it  for  operating  an  induction  coil 
from  an  alternating  circuit,  and  obtain  unidirectional  dis- 
charges from  the  secondary.  The  interruptions  occur,  of 
course,  only  while  the  current  flows  in  such  a  direction  that 
hydrogen  is  liberated  at  the  platinum  electrode.  The  current 
waves  in  the  opposite  direction  produce  no  interruptions,  and 
no  sparks  at  the  secondary.*  The  discharges  which  are  pro- 
duced from  an  induction  coil  in  this  way  are  very  satisfactory 
for  exciting  x-ray  tubes,  but  it  is  impossible  to  obtain  as  much 
energy  from  the  coil  as  it  will  give  with  the  direct  current 
and  the  same  interrupter.  Moreover,  with  the  alternating 
the  platinum  wears  away  very  rapidly  and  causes  considerable 
annoyance  and  trouble.  With  the  direct  current  the  wearing 
away  of  the  platinum  is  so  little  that  it  is  not  a  serious  ob- 
jection. When  the  alternating  current  is  used  with  this  inter- 
rupter, the  reversals  in  direction  of  the  current  tend  to  free 
the  platinum  point  from  any  bubbles  of  gas  which  tend  to 
collect,  and  its  action  is  very  much  steadier,  and  may  be  pro- 
longed for  a  greater  period  than  is  possible  with  the  direct 
current. 

The  frequency  of  interruptions  with  this  apparatus  will 
depend  somewhat  upon  the  strength  of  the  current  passing 
through  it,  and  upon  the  amount  of  surface  of  platinum  exposed 
to  the  electrolyte.  In  a  common  form  of  the  instrument  the 
platinum  electrode  is  in  the  form  of  a  wire  which  is  enclosed 
in  a  porcelain  tube,  and  the  amount  of  its  projection  below 

*  The  rate  of  change  of  the  strength  of  current  of  commercial  alternating  cur- 
rent systems  is  not  rapid  enough  to  produce  long  sparks  in  an  ordinary  induc- 
tion coil. 


ELECTROLYTIC  INTERRUPTERS. 


81 


the  tube  into  the  liquid  may  be  adjusted  by  means  of  a  screw. 
In  this  way  it  is  possible  to  adjust  the  apparatus  for  inter- 
ruptions of  various  frequencies,  and  to  compensate  for  the 
wearing  away  of  the  platinum  when  the  alternating  current 
is  used.  This  interrupter  is  shown  in 
figure  35.  f ©9 

One   of   the   best   forms   of  Wehnelt 
interrupter   is   one   which  was  devised          $ 
by  Dr.  Crane,  of  Kalamazoo,  and  which  * 

is  especially  well  adapted  for  use  with 
alternating  currents. 

In  this  interrupter  the  platinum  elec- 
trode consists  of  a  short  piece  of  plati- 
num wire  of  large  diameter  placed  in 
the  end  of  a  glass  tube  from  which  it  is 
separated  b}^  a  short  length  of  rubber 


Fig.  35. — Wehnelt  interrupter  with  screw 
adjustment  for  regulating  the  amount  of  platinum 
exposed  to  the  liquid. 


Fig.  36.— Crane's 
platinum  electrode  for 
Wehnelt  interrupter. 


tubing.  The  connection  with  the  platinum  electrode  is  made 
by  means  of  a  copper  wire  and  a  little  mercury  poured  in  the 
tube  to  make  connection  between  the  wire  and  the  platinum. 
Only  the  end  of  the  platinum  wire  is  exposed  to  the  liquid,  and 
6 


82  INDUCTION    COILS   AND    INTERRUPTERS. 

in  practice  the  glass  tube,  the  rubber  tube,  and  the  platinum 
wear  away  at  about  the  same  rate,  so  that  such  an  interrupter 
may  be  used  with  the  alternating  current  for  a  considerable 
time  without  adjustment.  (See  Fig.  36.) 

An  excellent  form  of  Wehnelt  interrupter  for  use  with  the 
alternating  current  was  described  by  Messrs.  Gaiffe  and  Galliot 


Fig.  37. — Gaiffe  and  Galliott's  modification  of  Wehnelt  interrupter  for  use  with 
alternating  currents. 

in  the  Archives  of  the  Rontgen  Ray  for  July,   1902,  and  is 
shown  in  figure  37. 

It  will  be  seen  that  in  this  interrupter  the  platinum  electrode 
slips  easily  through  a  porcelain  tube  and  rests  upon  an  insulating 
support  a  short  distance  beneath  it.  As  the  end  of  the  wire 
wears  away,  a  fresh  portion  of  the  wire  is  fed  through  the 
tube  by  gravity,  and  thus  an  approximately  constant  amount 
of  surface  is  exposed,  regardless  of  the  wear.  In  order  to 
adjust  the  frequency  of  interruptions  the  distance  between  the 


ELECTROLYTIC  INTERRUPTERS. 


83 


end  of  the  porcelain  tube  and  the  insulating  support  can  be 
varied  by  an  adjusting  screw,  and  thus  expose  more  or  less 
of  the  platinum  electrode  to  the  liquid.  This  is  perhaps  the 
most  satisfactory  type  of  Wehnelt  interrupter  for  use  with 
the  alternating  current. 

In  the  New  York  Electrical  Review,  May  4,  1899,  I  described 
a  form  of  interrupter  *  which  is  similar  in  appearance  to  that 
of  Wehnelt,  but  which  differs  from  it  in  some  important  essen- 
tials. A  diagram  of  this  interrupter  is  shown  in  figure  38.  It 
consists  of  a  jar  containing  dilute  sulphuric  acid,  within  which 
is  a  cup  of  insulating  material  perforated  by  a  small  hole.  Lead 
electrodes  are  placed  in 
the  outer  jar  and  in  the 
insulating  cup. 

When  the  primary  cur- 
rent of  an  induction  coil  is 
passed  through  this  appa- 
ratus, there  is  compara- 
tively little  heating  of  the 
liquid  except  in  the  aper- 
ture connecting  the  two 
chambers,  where  the  cur- 
rent density  is  very  large 
on  account  of  the  small 
area  of  the  aperture.  At 
this  point,  therefore,  suffi- 
cient heat  is  developed  to 

rapidly  vaporize  the  liquid,  and  bubbles  of  steam  which  form 
break  the  connection  between  the  liquid  in  the  inner  jar  and 
that  in  the  outer  jar.  As  soon  as  the  current  is  broken  the 
heating  stops  and  the  two  portions  of  the  liquid  come  together 
again,  completing  the  circuit.  The  frequency  of  the  interrup- 
tions will  depend  upon  the  strength  of  the  current,  the  size  of 
the  aperture,  the  resistance  of  the  electrolyte,  and  to  some  ex- 
tent upon  the  inductance  of  the  circuit.  An  arrangement  for 
varying  the  frequency  of  interruption  by  adjusting  the  size  of 

*This  type  of   interrupter  was  invented   independently  by  Dr.  Simon,  of 
Berlin,  and  was  published  by  him  in  Germany  about  the  same  time. 


Fig.  38. — Cald well's  liquid  interrupter. 


84 


INDUCTION   COILS   AND    INTERRUPTERS. 


the  aperture  was  described  by  the  author  in  the  New  York 
Electrical  Review,  May  11,  1899,  and  is  shown  in  the  diagram 
in  figure  39.  In  this  arrangement  the  aperture  is  at  the  bottom 
of  the  inner  cup.  It  is  partly  closed  by  a  pointed  rod  of  non- 
conducting material  which  protrudes  through  it.  By  raising  or 
lowering  the  protruding  point  the  cross-section  of  the  annular 
aperture  between  it  and  the  cup  may  be  varied,  and  thus  the 
frequency  of  interruptions  adjusted  through  a  wide  range.  Mr. 
A.  A.  Campbell  Swinton  devised  a  screw  adjustment  for  the 
regulating  rod  of  this  interrupter. 

This  interrupter  is  not  so  susceptible  to  changes  in  the 
strength  of  the  exciting  current,  or  to 
changes  in  the  temperature  of  the  liquid, 
as  the  Wehnelt.  It  will  therefore  remain 
in  operation  somewhat  longer,  and  admits 
of  a  wider  range  of  adjustment  of  the  ex- 
citing current.  The  action  of  this  inter- 
rupter is  quite  independent  of  the  direc- 
tion of  the  current  through  it,  therefore 
when  employed  for  operating  induction 
coils  on  the  alternating  current  circuit 
the  current  will  be  broken  at  each  alter- 
nation and  the  secondary  discharges  will 
alternate  in  direction.  Such  discharges 
are  not  suitable  for  operating  single  focus 
tubes,  and  the  interrupter  is  therefore  not 
adapted  so  well  for  alternating  currents  as 
the  Wehnelt  interrupter.  With  the  alter- 
nating current  it  is  possible  to  use  double  focus  tubes,  but  these 
are  usually  unsatisfactory  except  for  therapeutic  purposes. 

Dr.  Ruhmer,  of  Berlin,  has  devised  a  modification  of  this 
interrupter  in  which  the  two  portions  of  the  liquid  are  con- 
tained in  separate  jars  which  are  clamped  together  and  which 
communicate  with  each  other  through  a  small  aperture  in  a 
porcelain  disc  between  them. 

With  the  electrolytic  or  liquid  interrupters  there  is  produced 
a  mixture  of  oxygen  and  hydrogen,  which  if  confined  may 
explode.  They  should  therefore  not  be  enclosed  in  a  tight 


ML/ 


Fig.  39. — Diagram 
showing  method  of 
regulating  size  of  aper- 
ture in  liquid  inter- 
rupter. 


CONDENSERS.  85 

box,  but  freely  ventilated  so  that  the  gas  may  escape.  They 
give  off  acid  fumes  which  are  disagreeable.  If  they  are  to 
be  used  for  long  periods,  it  will  be  well  to  have  them  placed 
in  a  cellar,  or  some  point  distant  from  the  operating-room, 
and  connected  to  the  exciting  apparatus  by  wires.  The  liquid 
commonly  employed  in  them  is  dilute  sulphuric  acid,  sp.  gr. 
1200;  and  this,  of  course,  will  cause  serious  damage  to  carpets 
and  furniture  in  case  it  becomes  accidentally  spilled.  The 
electrolyte  is  slowly  evaporated  by  the  high  temperature  pro- 
duced, and  must  occasionally  be  renewed,  perhaps  once  in 
three  or  four  months.  With  most  induction  coils  these  inter- 
rupters operate  better  without  a  condenser.  They  require 
comparatively  little  attention,  and  they  enable  a  greater  amount 
of  energy  to  be  taken  from  a  coil  than  can  be  obtained  with 
any  other  type  of  interrupter.  They  are,  therefore,  especially 
adapted  for  the  most  rapid  radiographic  work,  where  the 
exposure  will  not  be  longer  than  a  few  seconds.  They  may 
be  operated  continuously  for  half  an  hour  or  more,  but  when 
this  is  done  there  is  considerable  change  in  the  temperature 
of  the  liquid,  gas  collects,  and  the  action  is  not  so  satisfactory. 
Therefore  they  are  not  well  adapted  for  continuous  operation 
of  induction  coils,  although  they  may  be  used  for  this  purpose 
if  several  interrupters  are  provided,  and  the  connections  are 
changed  from  one  to  the  other,  thus  giving  each  one  an  interval 
of  rest. 

Condensers. — In  order  to  lessen  sparks  which  occur  at  the 
point  of  interruption  of  the  primary  current  of  the  induction 
coil  it  is  necessary,  with  all  interrupters  except  those  of  the 
liquid  or  electrolytic  types,  to  use  an  appliance  called  a  con- 
denser. 

This  condenser  consists  of  a  number  of  sheets  of  metal  foil 
laid  up  together  with  sheets  of  insulating  material  between 
them.  The  alternate  metal  sheets  are  connected  together, 
forming  two  sets  of  conductors  of  large  surface  which  are 
insulated  from  each  other  by  intervening  sheets  of  insulating 
material,  and  therefore  have  large  electrostatic  capacity.  When 
the  terminals  of  such  a  condenser  are  connected  to  the  contact 
points  between  which  the  primary  current  is  broken,  the  dis- 


86  INDUCTION    COILS  AND    INTERRUPTERS. 

charge  which  would  otherwise  cause  an  arc  to  pass  between  these 
points,  and  impair  the  sharpness  of  the  interruption,  passes 
into  the  condenser  and  stores  up  in  it  an  electrical  charge. 

These  condensers  are  made  in  a  variety  of  forms,  but  in  nearly 
all  of  them  the  metal  sheets  are  of  tinfoil.  In  some  of  them 
the  insulating  material  between  the  layers  of  tinfoil  consists 
of  waxed  paper;  in  others  it  is  thin  sheets  of  mica.  The 
dielectric  properties  of  mica  are  better  than  those  of  paper, 
and  the  mica  condensers  are  a  little  more  satisfactory  in  their 
operation.  They  are  also  much  lighter,  and  smaller  for  a 
given  capacity  than  the  condensers  with  paper  insulation,  and 
are  therefore  preferable  when  the  question  of  weight  is  to  be 
considered.  Well-constructed  paper  condensers,  however,  an- 
swer very  well,  and  they  are  very  much  cheaper  than  mica 
condensers. 

In  order  to  obtain  the  best  effects  of  the  condenser  with 
large  coils  it  is  necessary  to  be  able  to  adjust  its  capacity  to 
suit  the  strength  of  the  exciting  current  and  frequency  of 
interruptions.  This  is  usually  accomplished  by  a  small  switch 
having  several  points  by  means  of  which  the  number  of  sheets 
of  tinfoil  connected  in  the  circuit  may  be  varied. 

Rheostats. — If  the  induction  coil  is  operated  from  a  storage 
battery  circuit,  it  will  usually  be  possible  to  obtain  satisfactory 
regulation  of  the  output  by  varying  the  number  of  the  cells 
in  the  circuit.  A  certain  amount  of  regulation  may  also  be 
made  by  adjustment  of  the  interrupter. 

If  the  coil  is  to  be  operated  from  an  electric  lighting  circuit, 
it  will  be  necessary  to  have  in  series  with  it  an  adjustable 
rheostat  for  controlling  the  strength  of  the  current  supplied 
to  it.  The  regulation  of  the  current  strength  is  effected  by 
a  sort  of  switch  mechanism  which  cuts  in  the  circuit  more  or 
less  of  the  resistance  wire  of  the  rheostat.  Rheostats  suitable 
for  this  purpose  are  made  by  a  number  of  manufacturers  of 
electrical  apparatus,  and  most  of  them  are  very  good.  A 
rheostat  will,  of  course,  be  supplied  by  the  dealer  who  supplies 
the  induction  coil,  but  it  is  a  good  idea  to  examine  it  carefully 
to  see  that  it  has  sufficient  resistance  to  reduce  the  secondary 
discharges  until  they  are  just  strong  enough  to  excite  a  small 


SWITCHES — FUSES.  87 

tube,  to  see  that  there  are  a  sufficiently  large  number  of  contact 
points  so  that  accurate  regulation  may  be  obtained,  and,  finally, 
to  see  that  the  carrying  capacity  is  great  enough  so  that  the 
rheostat  does  not  become  overheated  with  a  run  of  five  or  ten 
minutes  at  the  full  capacity  of  the  coil.  As  a  measure  of 
safety  it  is  a  good  idea  to  place  a  stop  on  the  rheostat  at  the 
point  which  allows  the  maximum  current  which  will  be  used  to 
flow.  This  will  prevent  sending  unduly  strong  currents  through 
the  coil  by  accident.  If  the  electrolytic  interrupters  are  to  be 
used,  however,  it  will  be  necessary  at  times  to  get  all  the 
rheostat  resistance  out  of  the  circuit,  and  such  a  stop  will  then 
be  very  inconvenient. 

The  use  of  a  rheostat  when  the  exciting  current  is  obtained 
from  a  storage  battery  will  sometimes  admit  of  closer  regulation 
than  can  be  obtained  by  varying  the  number  of  cells,  and  has 
the  advantage  that  all  the  cells  of  the  storage  battery  will  be 
discharged  to  the  same  extent. 

With  those  interrupters  in  which  the  regulation  is  effected 
by  varying  the  relative  periods  of  make  and  break  of  the 
primary  current  the  rheostat  is,  of  course,  unnecessary,  but 
will  often  be  a  convenience. 

Switches. — It  is  usual  to  provide  the  induction  coil  with  some 
means  for  reversing  the  direction  of  the  current  through  the 
primary  coil.  The  simplest  arrangement  for  this  purpose  is  a 
double-pole,  double-throw  knife  switch.  This  switch  serves  not 
only  for  opening  and  closing  the  circuit,  but  controls  the  direc- 
tion of  the  current  through  the  coil  according  to  the  position 
in  which  it  is  closed.  It  is  convenient  to  have  the  connections 
made  so  that  when  the  switch  is  closed  the  handle  points  in 
the  direction  of  the  positive  terminal  of  the  secondary  coil. 
If  the  coil  has  two  or  more  separate  windings  in  the  primary, 
the  same  kind  of  switch  may  be  used  for  connecting  them 
either  in  series  or  parallel.  In  the  German  coils  this  is  usually 
effected  by  some  plugging  device,  such  as  was  shown  in  figure  25. 

Fuses. — In  order  to  prevent  a  dangerously  large  current  from 
flowing  through  the  coil  through  any  accident  there  is  usually 
included  in  the  circuit  a  piece  of  wire  of  low  melting-point, 
which  becomes  fused  and  opens  the  circuit  when  the  current 


88  INDUCTION    COILS   AND    INTERRUPTERS. 

becomes  too  strong.  Such  devices  are  commonly  known  as 
fuses,  and  are  used  everywhere  for  protecting  all  kinds  of 
electrical  circuits.  Sometimes  the  fuse  is  mounted  on  the  base 
of  the  coil,  or  sometimes  at  the  wall  terminal  of  the  electric 
lighting  circuit.  It  will  be  convenient  to  have  near  the  x-ray 
machine  a  fuse  which  may  be  readily  replaced,  and  which  is 
of  such  size  that  it  will  burn  out  before  the  most  distant  fuses 
in  the  lighting  circuit.  This  will  often  save  annoyance  and 
the  trouble  of  hunting  in  cellars  or  other  places  to  find  where 
the  fuse  has  blown  out.  A  supply  of  extra  fuse  wires  or  plugs 
should  be  kept  on  hand  so  that  when  one  burns  out  it  may 
be  quickly  replaced. 

Meters. — Although  not  a  necessity,  it  is  often  a  great  con- 
venience to  have  in  circuit  with  the  induction  coil  an  ammeter 
which  indicates  the  strength  of  the  exciting  current.  The  am- 
meter readings  are  useful  because  they  bear  a  more  or  less 
close  relation  to  the  amount  of  energy  supplied  to  the  tube, 
though,  to  be  sure,  this  relation  is  not  very  close  unless  the 
rate  of  interruption,  the  relative  period  of  make  and  break, 
and  the  vacuum  of  the  tube  remain  the  same  when  the  different 
readings  are  made.  When  these  conditions  can  be  kept  fairly 
constant,  the  ammeter  readings  are  of  considerable  value  in 
therapeutic  wrork  for  estimating  the  strength  of  the  discharge 
of  the  coil  or  the  intensity  of  x-rays.  Records  of  these  ammeter 
readings  enable  the  same  treatment  to  be  repeated  with  a 
fair  degree  of  accuracy. 

The  energy  of  a  single  discharge  from  the  induction  coil 
bears  a  close  relation  to  the  strength  of  the  exciting  current 
at  the  instant  it  is  broken  to  produce  such  a  discharge.  It 
must  be  remembered  that  the  current  which  operates  an  in- 
duction coil  is  rapidly  changing  in  strength  from  zero  to  a 
maximum,  at  which  point  it  is  broken,  and  following  such 
break  is  a  long  or  short  period  of  rest  before  the  circuit  is  closed 
again.  It  is  the  value  of  this  maximum  strength  which  is 
reached  just  before  the  circuit  is  broken  that  determines  the 
energy  of  the  secondary  discharge.  The  ammeter  does  not 
register  the  value  of  this  maximum  current,  but  in  a  more 
or  less  imperfect  manner  integrates  the  current  curves  and 


METERS.  89 

indicates  approximately  the  average  current  strength,  including 
the  periods  of  rest  following  each  break  when  the  current 
strength  is  0.  It  will  be  obvious,  therefore,  that  in  order  to 
use  the  ammeter  readings  as  a  measure  of  the  energy  supplied 
to  the  tube  it  will  be  necessary  that  the  frequency  and  character 
of  the  interruptions  remain  unchanged. 

The  ammeters  usually  employed  for  this  purpose  are  the 
ordinary  direct  reading  instruments  which  are  intended  for 
measuring  steady  currents.  The  accuracy  of  these  instruments 
when  used  for  measuring  intermittent  currents,  such  as  pass 
through  an  induction  coil,  is  not  very  great,  but  it  is  sufficiently 
good  for  practical  purposes.  If  the  greatest  accuracy  is  required 
in  these  current  measurements,  the  only  practical  direct  reading 
instrument  is  the  hot  wire  ammeter,  which  measures  equally 
well  currents  of  any  form — continuous,  alternating,  or  inter- 
rupted. It  may  be  shown  that  such  a  hot  wire  ammeter  con- 
nected in  series  with  an  ordinary  direct  current  meter  of  the 
magnetic  type  will  give  the  same  reading  as  the  direct  curent 
meter  when  a  steady  current  is  flowing.  If  the  current  is 
rapidly  interrupted,  the  reading  of  the  direct  current  meter  will 
be  somewhat  less  than  that  of  the  hot  wire  meter. 

A  voltmeter  will  be  useful  for  determining  the  condition  of 
storage  batteries;  but  if  the  current  supply  is  from  a  lighting 
or  power  circuit,  it  is  quite  unnecessary,  because  the  potentials 
of  these  circuits  are  fairly  constant.  In  recording  the  energy 
supplied  to  the  x-ray  tubes  which  are  used  in  therapeutic  work 
some  physicians  have  given  not  only  the  ammeter  readings, 
but  the  readings  of  the  voltmeter  connected  across  the  terminals 
of  the  source  of  current  supply.  At  first  thought  it  might  seem 
that  the  two  readings  must  bear  a  fixed  relation  to  each  other. 
This  would  be  true  if  the  current  was  perfectly  steady.  This, 
however,  is  not  the  case,  and  the  voltmeter  reading  in  con- 
nection with  the  ammeter  reading  does  to  a  certain  extent  give 
an  indication  of  the  character  of  the  interruptions  of  the  circuit, 
and  may  at  times  be  useful  for  obtaining  a  given  adjustment 
of  the  interrupter.  In  radiographic  and  fluoroscopic  work,  how- 
ever, the  voltmeter  reading  is  comparatively  unimportant. 


90  INDUCTION    COILS   AND    INTERRUPTERS. 

Induction  Coil  Installations. — The  ordinary  induction  coil 
outfit  consists  of  an  induction  coil,  vibrating  interrupter,  con- 
denser, switch  for  opening  and  closing  the  circuit,  and  some- 
times a  rheostat,  mounted  together  on  one  base.  It  may  be 
placed  upon  a  table  and  connected  with  a  storage  battery,  or 
an  electric  lighting  circuit,  or  other  source  of  electrical  energy. 
Such  outfits  are  sold  by  nearly  all  the  manufacturers  of  x-ray 
apparatus.  Figure  40  shows  a  common  form  of  this  apparatus. 


Fig.  40. — Induction   coil  with   independent   vibrating   interrupter,  adjustable 
condenser  switches,  etc.,  mounted  on  base. 

In  the  more  elaborate  outfits  it  is  usual  to  have  the  coil 
and  controlling  apparatus  mounted  separately.  The  common 
practice  in  Germany  is  to  fasten  the  coil  firmly  to  the  wall 
of  the  room  at  a  height  of  6  to  8  feet  from  the  floor  and  to 
mount  the  controlling  apparatus,  meters,  etc.,  upon  a  small 
table  which  may  be  moved  around  the  room  at  the  convenience 


INDUCTION    COIL   INSTALLATIONS. 


91 


of  the  operator.  Such  an  installation  is  shown  in  figure  41. 
The  advantage  of  this  arrangement  is  that  the  controlling 
devices  may  be  placed  in  such  a  position  that  the  operator 
may  have  them  at  hand  while  he  is  using  the  fluoroscope. 
One  of  the  disadvantages  of  the  method  is  that  the  high  potential 
\vires  from  the  coil  to  the  tube  must  be  long.  They  have 
greater  electrostatic  capacity,  there  is  more  danger  of  obtaining 


Fig.  41. — Induction  coil  mounted  on  wall  with  controlling  apparatus  on  mova- 
ble stand. 

a  shock  from  them,  and  the  brush  discharges  from  them  are 
more  noticeable  than  when  coil  and  tube  are  brought  close 
together. 

I  prefer  to  mount  the  coil  on  a  small  table  provided  with 
castors  so  that  it  may  be  moved  as  close  as  possible  to  the 
tube-holder  and  tube.  The  meters,  controlling  devices,  etc.,  are 


92  INDUCTION   COILS  AND   INTERRUPTERS. 

then  mounted  firmly  upon  a  switchboard  or  wall-plate  and 
connection  between  them  and  the  coil  is  made  by  flexible 
conducting  cords.  With  this  arrangement  the  lead  wires  be- 
tween the  coil  and  the  tube  are  very  short,  and  the  liability 
of  leakage  and  accidental  contact  with  them  is  reduced.  A 
firm,  solid  support  for  the  meters  is  better  than  a  movable 
apparatus  which  is  subject  to  jar  and  mechanical  shocks. 

An  x-ray  outfit  that  is  to  be  employed  for  a  variety  of  pur- 
poses— radiographic  work,  fluoroscopic  examinations,  and  x-ray 


Fig.  42. — Switchboard  Avith  movable  coil. 

treatment — should  be  supplied  with  at  least  two  interrupters, 
with  switching  or  plugging  devices  for  changing  from  one  to 
the  other.  For  the  fastest  radiographic  work  it  will  be  well 
to  employ  interrupters  of  the  liquid  or  electrolytic  type.  These 
interrupters,  however,  are  not  suitable  for  continued  use,  such 
as  may  be  required  for  long  fluoroscopic  examinations  or  thera- 
peutic applications  of  the  x-ray.  For  such  work  as  this  the 
mercury  interrupters  and  the  ordinary  vibrating  interrupter 
are  preferable.  These  types  of  interrupters  are  better  adapted 


PORTABLE    X-RAY   APPARATUS.  93 

for  long  runs,  and  with  them  a  wider  range  of  regulation  of 
the  exciting  current  is  possible. 

The  arrangement  of  switchboard  and  coil  at  the  Edward  N. 
Gibbs  X-ray  Laboratory  is  one  which  facilitates  the  changing 
the  connections  of  current  supply,  interrupters,  etc.  This  outfit 
is  shown  in  figure  42.  The  switchboard  carries,  in  addition 
to  the  meters,  a  rheostat,  a  condenser,  a  series  inductance 
coil,  all  of  which  are  adjustable  by  means  of  the  three  hand- 
wheels  shown.  The  connection  of  the  various  types  of  inter- 
rupters is  made  by  means  of  a  plug  and  flexible  cord  which 
is  connected  to  two  binding  posts  at  the  lower  right-hand 
corner  of  the  board.  Several  different  sources  of  exciting 
current  are  available,  and  these  may  be  selected  by  means 
of  a  similar  plug  and  flexible  cord  connected  at  the  upper 
right-hand  corner  of  the  board.  Underneath  the  board  is  a 
little  cupboard  for  the  liquid  and  electrolytic  interrupters. 
This  cupboard  connects  directly  with  a  flue  which  provides 
a  suitable  outlet  for  the  fumes  and  gases.  The  cupboard  is  so 
well  enclosed  that  the  noise  of  the  interrupters  is  not  offensive. 

Portable  X-ray  Apparatus. — Occasionally  it  is  necessary  to 
make  radiographs  at  the  bedside  of  a  patient  who  cannot  be 
moved.  These  cases  are  almost  invariably  those  in  which  the 
injury  is  in  the  thicker  parts  of  the  body,  and  powerful  appa- 
ratus will  therefore  be  necessary. 

The  ordinary  induction  coil  outfit  for  office  use  is  not  a 
readily  portable  machine,  and  the  static  machine  is,  of  course, 
quite  out  of  the  question  for  work  of  this  kind.  The  only 
thing  that  may  be  used  with  convenience  is  an  induction  coil 
outfit  of  moderate  size  which  is  arranged  to  be  easily  trans- 
ported without  risk  of  damaging  it.  A  considerable  experience 
in  moving  different  x-ray  outfits,  one  of  them  weighing  300 
pounds,  has  led  me  to  the  conclusion  that  the  best  arrangement 
of  a  portable  outfit  consists  in  dividing  it  up  into  a  number 
of  packages  none  of  which  shall  weigh  more  than  40  or  50 
pounds. 

The  simplest  portable  induction  coil  outfit  for  radiographic 
work  will  consist  of  the  induction  coil,  interrupter,  controlling 
devices,  tube-holder,  two  tubes,  plates  and  plate-holder,  and 


94 


INDUCTION   COILS   AND    INTERRUPTERS. 


storage  battery.     In  order  to  avoid  exceeding  the  weight  limit 
above  mentioned  and  to  carry  a  coil  which  is  large  enough 


Fig.  43. — Portable  induction  coil  and  portable  liquid  interrupter  closed,  ready 

for  transportation. 


Fig.  44. — Portable  induction  coil  ready  for  use,  showing  tube-holder  and  tube. 


for  the  most  difficult  work  it  will  be  necessary  to  have  at  least 
three  packages;  and  since  it  will  take  two  persons  to  carry 


PORTABLE    X-RAY   APPARATUS. 


95 


these,  it  is  just  as  well  to  have  the  outfit  divided  into  four 
packages.  If  the  outfit  is  to  be  operated  from  a  storage  battery, 
these  packages  will  be  as  follows:  (1)  induction  coil  with  tube- 
holder;  (2)  interrupter,  condenser,  and  connecting  cords  ;  (3) 
plates  and  plate-holder,  and  two  tubes;  and  (4)  storage  bat- 
tery. If  the  outfit  is  to  be  operated  from  an  electric  lighting 
circuit  or  from  a  100-volt  electric  automobile  storage  battery, 
the  arrangement  may  be  as  follows:  (1)  induction  coil,  with 
tube-holder;  (2)  portable  liquid  interrupter  with  100  feet  flexible 
cord  and  suitable  plugs  for  connecting  with  a  lamp  socket  or 
with  the  charging  socket  of  the  automobile;  (3)  plates,  plate- 
holder,  and  two  tubes. 

By  following  out  the  princi- 
ples of  design  mentioned  in 
the  early  part  of  the  chapter 
I  have  succeeded  in  obtaining 
a  coil  sufficiently  powerful  for 
radiographing  any  part  of  the 
body,  and  which  weighs  but  a 
little  more  than  40  pounds. 
Even  with  such  a  light  coil  as 
this,  in  order  to  avoid  exceed- 
ing the  weight  limit  of  50 
pounds  in  any  package,  it  is 
necessary  to  mount  the  con- 
denser and  interrupter  separ- 
ately. The  induction  coil  is  therefore  mounted  in  a  box  with 
adjustable  tube-holder,  adjustable  series  and  multiple  spark 
gaps,  spools  for  carrying  the  lead  wires  of  the  tube,  and  a 
switch  for  connecting  the  two  windings  of  the  primary  in  series 
or  parallel.  This  coil  with  the  above  accessories  is  shown  in 
figures  43,  44,  and  45.  For  use  with  exciting  current  at  100 
volts  or  more  the  primary  windings  are  connected  in  series. 
When  they  are  connected  in  parallel,  the  coil  works  very  well, 
with  six  storage  cells  and  a  vibrating  interrupter. 

A  portable  vibrating  interrupter  with  adjustable  mica  con- 
denser for  use  with  this  coil  is  shown  in  figure  46.     A  portable 


Fig.  45. — Portable  induction  coil  with 
case  opened. 


96 


INDUCTION    COILS    AND    INTERRUPTERS. 


electrolytic  interrupter  with  controlling  switches  is  shown  in 
figure  43.  The  tubes,  plates,  and  plate-holders  are  carried  in 
a  wooden  case  with  a  carrying  strap.  The  arrangement  of  this 


~         '  _  I   ,  / 


Fig.  46. — Portable  condenser  with  vibrating  interrupter. 


Fig.  47. — Portable  coil  with  vibrating  interrupter  and  condenser. 

portable  coil  and  tube-holder  is  such  that  it  may  be  con- 
veniently placed  upon  a  chair  at  the  side  of  a  bed,  and  sup- 
port the  tube  in  any  position  over  the  patient,  the  plate  being 
placed,  of  course,  underneath. 


PORTABLE    X-RAY    APPARATUS.  97 

Portable  induction  coils  of  somewhat  smaller  size  and  having 
the  condenser  and  vibrating  interrupter  mounted  with  them 
are  made  by  Queen  &  Co.,  Willy  oung,  and  others.  One  of 
these  coils  is  shown  in  figure  47. 


CHAPTER  IV. 
STATIC  MACHINES  AND  THEIR  MANAGEMENT. 

THE  static  machine,  although  it  is  large,  clumsy,  and  noisy 
in  operation,  and  is  subject  to  serious  disturbances  from  atmos- 
pheric changes,  has  been  used  extensively  for  exciting  Crookes 
tubes  for  x-ray  work.  It  is  claimed  that  various  electrical 
discharges  which  may  be  obtained  from  these  machines  have 
useful  therapeutic  properties,  and  long  before  the  discovery 
of  the  x-ray  hundreds  of  such  machines  were  sold  to  physicians 
in  this  country  for  use  in  electrical  treatments.  When  the 
x-ray  was  discovered,  the  man  who  owned  a  static  machine 
had  only  to  purchase  a  fluoroscope  and  a  Crookes  tube  and 
tube-holder  in  order  to  have  a  fairly  good  x-ray  outfit.  A 
few  men  have  obtained  excellent  radiographs  with  the  static 
machine,  and  there  are  some  who  prefer  it  to  every  other  appa- 
ratus for  exciting  x-ray  tubes. 

Although  the  static  machine  is  not  so  well  adapted  for  radio- 
graphic  work  as  the  induction  coil,  it  has  been  a  very  satisfactory 
apparatus  in  the  hands  of  many  physicians  who  employ  the 
x-ray  for  fiuoroscopic  examinations,  for  therapeutic  applications, 
or  perhaps  occasionally  for  minor  radiographic  work. 

On  account  of  the  steadiness  of  its  discharge  it  is  very  well 
adapted  for  exciting  Crookes  tubes  for  fiuoroscopic  work. 
There  is  much  less  heating  of  the  target  of  Crookes  tubes 
when  they  are  excited  by  a  static  machine  than  when  operated 
by  a  coil.  Lighter  and  cheaper  tubes  may  therefore  be  used 
with  a  static  machine,  and  their  deterioration  will  be  much 
less  rapid,  the  life  of  the  tube  being  very  much  increased. 
The  cost  of  tubes  is  quite  an  item  of  expense  in  running  an 
x-ray  outfit,  and  this  advantage  is  well  worth  considering. 
The  operation  of  a  static  machine  is,  for  most  people,  somewhat 
easier  than  that  of  an  induction  coil  with  its  troublesome 
interrupters. 


INFLUENCE   MACHINES.  99 

Modern  influence  machines,  or  so-called  static  machines,  do 
not,  as  is  often  supposed,  generate  electricity  by  friction,  but 
by  what  is  known  as  electrostatic  induction,  or  the  influence 
of  an  electrical  charge  upon  bodies  which  are  brought  into 
its  vicinity.  In  most  of  these  influence  machines  there  are  a 
number  of  circular  glass  plates  which  are  arranged  to  revolve 
in  close  proximity  to  two  sets  of  stationary  armatures  made 
of  paper  and  metal  foil.  High  potential  charges  are  maintained 
upon  the  two  armatures,  one  set  being  positive  and  the  other 
set  negative.  Portions  of  the  revolving  glass  plates  as  they 
approach  the  charged  armatures  have  their  electrical  condition 
disturbed  by  the  influence  of  these  charged  armatures.  While 
under  the  influence  of  the  armatures  a  rearrangement  of  the 
electrical  charge  on  the  surface  of  the  revolving  plates  takes 
place  through  toothed  brushes,  or  combs,  called  neutralizing 
combs,  which  connect  the  opposite  sides  of  the  revolving  plates 
which  are  under  the  influence  of  the  two  armatures.  When 
these  portions  of  the  revolving  glass  plate  have  passed  out 
of  the  influence  of  the  armatures,  and  away  from  the  neutral- 
izing combs,  they  possess  free  electrical  charges,  which  are 
then  removed  by  the  collecting  combs,  and  lead  out  to  the 
terminals  of  the  machine. 

The  two  types  of  influence  machines  which  are  commonly 
used  are  those  of  Holtz  and  Wlmshurst.  In  the  Wimshurst 
machine  the  revolving  plates  are  arranged  in  pairs  and  the 
charges  on  the  different  portions  of  one  plate  of  a  pair  act 
inductively  on  corresponding  portions  of  the  other  pair  in 
the  manner  just  described.  Nearly  all  of  the  static  machines 
sold  in  this  country  are  either  the  Holtz  type,  or  a  modification 
known  as  the  Toepler-Holtz.  In  England  and  France  the  Wims- 
hurst machines  are  more  in  use,  and  in  Germany  one  rarely 
sees  a  static  machine.  Nowhere  are  they  made  in  such  large 
sizes,  or  is  the  mechanical  construction  so  good,  as  in  this 
country. 

For  therapeutic  purposes  the  Holtz  machine  is  preferred  to 
the  Toepler-Holtz  because  its  discharge  is  steadier  and  less 
painful,  and  because  it  gives  longer  sparks.  For  x-ray  work 
there  is  very  little  difference  in  the  efficacy  of  the  two  types. 


100  STATIC   MACHINES   AND   THEIR   MANAGEMENT. 

With  the  Holtz  type  the  armatures  are  liable  to  become 
discharged  when  the  machine  stops,  and  it  is  customary  to 
employ  a  very  small  Wimshurst  or  Toepler-Holtz  for  giving 
the  armatures  the  initial  charge  which  is  necessary  to  put 
the  apparatus  in  operation.  Both  the  Wimshurst  and  Toepler- 
Holtz  machines  are  self-charging. 

The  influence  machines  operate  better  with  tubes  of  high 
resistance  such  as  are  suitable  for  fluoroscopic  work  than 
with  the  low  resistance  tubes  which  are  usually  desirable  for 
radiographic  work.  One  reason  for  this  is  that  the  electrical 
charges  of  the  armatures  are  collected  from  the  revolving 
plates,  and  the  potential  of  these  revolving  plates  will  depend 
somewhat  upon  the  resistance  of  the  tube  which  is  connected 
with  the  terminals  of  the  machine.  If  the  tube  is  of  high 
resistance,  the  difference  of  potential  at  the  terminals  of  the 
machine  will  be  great,  and  it  will  be  easy  to  maintain  high 
potential  charges  in  the  armatures,  but  if  a  low  resistance 
tube  is  connected  across  the  terminals  of  the  machine,  the 
difference  of  potential  between  the  armatures  will  be  reduced 
to  a  greater  or  less  extent.  The  output  of  the  static  machine, 
other  things  being  equal,  varies  directh-  with  the  difference 
of  potential  upon  the  armatures,  which  act  in  this  respect 
somewhat  like  the  field  magnets  of  a  dynamo. 

The  charge  which  is  derived  from  the  revolving  plates  for 
maintaining  the  potentials  in  these  armatures  is,  in  the  Holtz 
machine,  collected  at  about  the  same  point  that  the  collector 
combs  are  connected  with  the  terminals  of  the  machine.  If 
a  tube  of  low  vacuum  is  used,  the  potentials  of  these  terminals 
will  fall,  and  of  course  the  potential  of  the  armatures  will 
fall  correspondingly.  The  machine  will  then  be  working  at  a 
disadvantage,  it  will  absorb  less  energy  from  the  motor  and 
will  deliver  less  electrical  energy  to  the  tube.  In  the  Toepler- 
Holtz  machine  the  charge  for  the  armatures  is  collected  from 
the  revolving  plates  before  their  charge  has  been  reduced  by 
the  collectors  connected  with  the  terminals.  In  this  type  of 
machine,  therefore,  the  potential  of  the  armatures  is  not  quite 
so  much  affected  by  the  potential  at  the  terminals,  and  it  is 
a  little  better  adapted  for  use  with  tubes  of  low  resistance. 


INFLUENCE    MACHINES. 


101 


I  have  found  in  the  Holtz  machine  that  it  is  possible  to 
prevent  to  some  extent  this  reduction  of  the  armature  potential 
by  turning  the  collector  combs  of  the  terminals  beyond  the 
point  where  the  charge  for  the  armature  is  collected,  so  that 


the  armature  collects  its  charge  first  from  the  plate  before 
the  potential  has  been  reduced  by  the  collector  combs.  This 
change  can  be  made  without  trouble  in  many  of  the  Holtz 
machines,  and  although  it  materially  reduces  the  length  of  spark 
which  it  is  possible  to  obtain,  it  increases  the  power  of  the 


< 


Fig.  49. — Ordinary  type  of  Holtz  machine. 


Fig.  50. — Toepler-Holtz  machine. 
102 


SIZE    OF    MACHINE. 


103 


discharges  at  such   potentials  as  will  be  used  for  operating 
x-ray  tubes. 

A  Holtz  machine  made  by  Waite  &  Bartlett  and  having 
24  revolving  plates,  and  having  the  collector  combs  arranged 
in  this  manner,  is  shown  in  figure  48.  The  ordinary  types 
of  the  Holtz  and  Toepler-Holtz  machines  are  shown  in  figures 
49  and  50.  A  Wimshurst  machine  made  by  Newton  &  Co., 
London,  is  shown  in  figure  51. 


Fig.  51. — Wimshurst  influence  machine. 

Size  of  Machine. — The  influence  machines  usually  sold  in 
this  country  have  from  6  to  16  revolving  plates,  from  26  to 
32  inches  in  diameter.  Some  machines  have  been  made  with 
a  large  number  of  small  plates,  and  others  with  few  plates 
of  very  large  diameter.  Those  of  Dr.  Williams  and  Dr.  Rollins 
have  revolving  plates  of  thick  glass  about  6  feet  in  diameter. 

The  generating  capacity  of  a  static  machine  bears  a  fairly 
close  relation  to  the  area  of  revolving  plates  exposed  to  the 
inductive  action  of  the  armatures.  Longer  sparks  may  be 


104  STATIC    MACHINES   AND    THEIR    MANAGEMENT. 

obtained  from  machines  with  plates  of  large  diameter,  but 
what  is  needed  for  x-ray  work  is  not  long  sparks,  but  powerful 
discharges  at  a  difference  of  potential  which  would  produce 
sparks  of  only  a  few  inches,  or  very  much  shorter  than  the 
sparking  distance  of  the  ordinary  static  machine.  The  me- 
chanical construction  of  a  machine  having  sufficient  surface 
for  producing  such  discharges  is  made  easier  by  having  a 
large  number  of  plates  of  small  diameter  than  with  a  few  plates 
of  large  diameter.  The  best  diameter  for  the  revolving  plates 
is  about  30  inches.  This  is  the  size  which  has  been  adopted 
by  most  of  the  makers.  A  static  machine  for  x-ray  work 
should  have  not  less  than  10  or  12  revolving  plates  30  inches 
in  diameter.  Such  a  machine  will  be  large  enough  for  fluoro- 
scopic  examinations  of  any  part  of  the  body.  Machines  of  16 
or  20  plates  will  be  more  powerful  and  somewhat  shorter 
radiographic  exposures  may  be  obtained  with  them,  but  for 
this  work  the  largest  static  machine  that  can  be  built  will  be 
much  inferior  to  a  fair-sized  induction  coil. 

Hard-rubber  and  Mica  Plates. — On  account  of  the  fragile 
nature  of  glass  some  makers  have  made  the  revolving  plates 
of  hard-rubber,  or  of  a  mixture  of  mica  and  shellac,  with  the 
object  of  enabling  higher  speeds  to  be  obtained  with  safety, 
thus  giving  greater  output  for  a  given  number  of  plates.  There 
is  abundant  proof  that  with  the  increase  of  speed  there  is 
increase  in  output,  but  it  is  doubtful  whether  the  advantages 
of  reducing  the  number  of  plates  in  this  way  are  sufficient 
to  compensate  for  the  troubles  incident  to  running  such  a 
machine  at  a  very  high  rate  of  speed.  Moreover,  there  is 
always  some  question  about  the  lasting  qualities  of  the  sub- 
stances which  have  been  used  as  substitutes  for  the  glass  plates. 

Hard-rubber  deteriorates  very  rapidly,  and  is  quite  unsuit- 
able, although  a  large  output  may  be  obtained  from  a  hard- 
rubber  plate  machine  when  it  is  new.  Mica  plate  machines 
have  been  run  at  a  speed  of  2000  revolutions  per  minute.  The 
ordinary  speed  for  a  glass  plate  machine  having  revolving 
plates  30  inches  in  diameter  is  not  more  than  three  to  four 
hundred  revolutions  per  minute. 

Regulating  the  Discharge. — The  usual  method  of  controlling 


REGULATING   THE    DISCHARGE. 


105 


the  output  of  the  static  machine  is  by  varying  its  speed.  If 
the  machine  is  operated  by  a  direct  current  motor,  the  speed 
of  this  motor  may  be  varied  within  wide  limits  by  means  of 
a  small  speed-regulating  rheostat.  A  small  alternating  current 
motor  such  as  would  be  employed  for  this  purpose  runs  at 
a  constant  speed,  which  is  determined  by  the  number  of  poles 
in  the  field  magnet  of  the  motor,  and  the  frequency  of  alterna- 
tions in  the  power  circuit.  When  such  a  motor  is  used,  the 
speed  of  the  static  machine  may  be  regulated  by  means  of  a 
variable  friction  gear  device  connected  between  the  motor  and 
the  machine.  One  of  these  arrangements  is  shown  in  figure  52. 


Fig.  52. — Friction  speed  controller  for  influence  machine. 

They  are,  of  course,  wasteful  of  power,  but  for  running  small 
machines  will  be  satisfactory.  Sufficient  regulation  of  the 
speed  for  ordinary  purposes  may  be  obtained  by  the  use  of 
cone  pulleys,  though  of  course  such  an  arrangement  is  not 
convenient  because  the  machine  must  be  stopped  and  the 
belt  rearranged  in  order  to  obtain  a  change  of  speed.  With 
most  static  machines,  however,  there  is  no  necessity  for  speed 
regulation  in  the  operation  of  x-ray  tubes.  It  will  usually  be 
found  that  the  maximum  amount  of  energy  which  can  be 
obtained  from  the  machine  at  full  speed  will  not  be  too  much. 


106  STATIC   MACHINES   AND   THEIR   MANAGEMENT. 

It  has  been  proposed  to  control  the  output  of  the  static  machine 
without  changing  its  speed  by  shifting  the  position  of  the 
neutralizing  combs. 

Enclosing  Case  for  Static  Machine. — In  order  to  protect  the 
machine  from  dust  and  moisture  it  is  necessary  to  enclose 
it  in  a  case  which  should  be  as  nearly  dust-  and  air-proof  as 
possible.  The  case  is  ordinarily  made  of  a  framework  of  wood 
with  large  glass  panes  in  it.  In  order  to  prevent  leakage  of 
the  discharge  the  case  should  be  so  large  that  there  will  be 
a  distance  of  not  less  than  8  or  10  inches  between  it  and  the 
nearest  part  of  the  revolving  plates.  In  most  of  the  static 
machines  made  in  this  country  the  front  and  back  of  the  case 
form  supports  for  the  shaft.  This  is  not  the  best  possible 
mechanical  construction,  but  it  has  been  adopted  by  nearly 
all  makers.  Therefore  in  selecting  a  machine  it  is  well  to 
see  that  the  parts  of  the  case  which  support  the  bearings  of 
the  shaft  are  heavy  and  strong  enough  for  this  purpose.  The 
sides  of  the  case  should  be  readily  removable  to  facilitate 
getting  at  the  inside  for  changing  the  drier,  or  cleaning  or 
airing  the  machine.  It  will  be  convenient  to  have  in  one  side 
of  the  case  a  small  door  which  may  be  quickly  and  easily  opened 
and  closed.  Such  an  arrangement  would  very  materially  facili- 
tate the  changing  of  the  drier  in  the  machine,  especially  in 
damp  weather,  when  it  is  undesirable  to  let  the  case  remain 
open  for  any  length  of  time.  It  is  important  that  the  case 
should  be  accurately  fitted  and  made  of  well-seasoned  wood, 
which  will  not  shrink  or  warp  with  the  result  of  producing 
cracks  which  allow  dust  and  moisture  to  enter,  or  perhaps 
even  throwing  the  bearings  of  the  shaft  out  of  alignment. 

Ozone  and  Nitrogen  Oxids. — In  the  operation  of  the  machine 
some  of  the  oxygen  of  the  air  within  the  case  is  converted 
into  ozone.  At  the  same  time  there  are  formed  certain  com- 
pounds of  the  oxygen  and  nitrogen  in  the  air  which  are  more 
or  less  corrosive  and  somewhat  hygroscopic.  "When  these  sub- 
stances collect  in  considerable  quantities,  the  efficiency  of  the 
machine  is  seriously  impaired.  It  is  therefore  a  good  idea 
occasionally  to  open  the  case  and  thoroughly  ventilate  it  for 
an  hour  or  two. 


DISTURBING    EFFECTS   OF   MOISTURE.  107 

Disturbing  Effects  of  Moisture. — When  there  is  enough  mois- 
ture in  the  air  so  that  it  is  liable  to  condense  upon  the  different 
parts  of  the  machine,  it  interferes  very  seriously  with  its  opera- 
tion. During  the  summer  months  and  in  damp  places  it  will 
usually  be  necessary  to  employ  some  artificial  means  for  keeping 
the  inside  of  the  case  dry.  The  ordinary  method  is  to  place 
within  the  case  one  or  two  vessels  containing  about  ten  to 
twenty  pounds  of  calcium  chlorid  which  has  been  thoroughly 
baked.  After  a  while  this  calcium  chlorid  will  become  sat- 
urated with  water,  and  useless.  Therefore  it  must  be  removed 
occasionally  and  baked  out  again  for  several  hours.  Lime  has 
also  been  used  for  this  purpose,  and  it  is  claimed  that  this 
substance  takes  up  not  only  the  moisture  but  the  compounds 
of  oxygen  and  nitrogen.  If  lime  is  employed,  the  vessel  con- 
taining it  must  be  tightly  covered  with  cloth  of  fine  mesh 
in  order  to  prevent  the  dust  of  the  slaked  lime  from  getting 
out  into  the  case,  where  it  would  be  carried  around  by  the 
air-currents  and  electrical  charges.  It  has  been  recommended 
that  a  jar  of  calcium  chlorid  and  a  jar  of  lime  be  used  at  the 
same  time. 

Sometimes  instead  of  drying  the  air  hi  the  case  it  is  warmed 
by  means  of  incandescent  lamps  or  an  electric  heater.  Of 
course,  when  the  air  is  warmed  it  has  a  greater  capacity  for 
moisture,  which  therefore  does  not  become  condensed  out  on  the 
machine  and  destroy  its  insulation.  Usually  it  is  more  satisfac- 
tory to  dry  the  air.  In  damp  weather  it  is  a  good  idea  to  wipe 
off  the  terminals  and  discharge  rods  of  the  machine,  especially 
the  hard-rubber  insulating  sleeves  supporting  the  terminals, 
with  a  very  warm,  very  dry  rag,  in  order  to  remove  all  of  the 
moisture.  The  metal  parts  of  the  terminals  should  always  be 
kept  clean  and  bright  and  free  from  dust  or  corrosion. 

Oiling  the  Machine. — It  is,  of  course,  necessary  in  any  machine 
which  runs  at  three  or  four  hundred  revolutions  per  minute 
to  keep  the  bearings  well  oiled.  In  the  static  machine  the 
oil  at  the  ends  of  the  bearings  which  project  within  the  case  is 
especially  liable  to  become  sticky  and  gummy.  It  is  necessary 
occasionally  to  flush  out  the  bearing  with  some  thin  oil  which 
will  dissolve  out  the  hardened  machine  oil.  With  a  static 


108  STATIC    MACHINES   AND    THEIR    MANAGEMENT. 

machine  having  ball  bearings  the  oiling,  of  course,  will  not 
have  to  be  done  so  frequently  as  in  those  having  the  ordinary 
bronze  bearings.  The  bronze  bearings,  although  they  require 
more  attention,  are  to  my  mind  preferable  because  they  are 
not  so  noisy. 

Series  Spark  Gap. — Every  static  machine  which  is  to  be  used 
for  x-ray  work  should  be  provided  with  some  sort  of  an  adjust- 
able spark  gap  which  may  be  placed  in  circuit  with  the  lead 
wires  to  the  Crookes  tube.  If  the  tube  is  of  proper  vacuum 
its  terminals  may  be  connected  directly  with  the  terminals 
of  the  static  machine.  If  the  tube  is  a  little  too  low  in  vacuum, 
it  may  be  made  to  work  better  by  inserting  a  small  series  spark 
gap  on  one  side  or  the  other,  perhaps  on  both  sides.  It  will 
be  found  that  some  tubes  work  better  with  the  gap  on  the 
negative,  and  others  with  the  gap  on  the  positive,  side.  The 
series  spark  gap  also  lessens  the  tendency  to  brush  discharges 
and  sparking  from  the  lead  wires  and  other  exposed  metal 
parts  of  the  circuit.  The  arrangement  for  producing  this  spark 
gap  may  be  a  simple  sliding  metal  rod  with  a  ball  terminal, 
which  may  be  fastened  to  the  hard -rubber  handle  of  the  dis- 
charge rods  of  the  machine,  but  it  is  better  to  use  some  modifi- 
cation of  the  Williams  multiple  spark  gap,  which  is  described 
more  fully  in  the  chapter  on  fluoroscopy. 

Polarity. — Before  connecting  the  Crookes  tube  to  a  static 
machine  it  is,  of  course,  necessary  to  determine  the  polarity 
of  its  terminals.  This  may  be  done  in  various  ways.  The 
quickest  way  is  by  observing  the  character  of  the  sparks  which 
pass  between  the  discharge  rods.  After  a  little  practice  one 
will  readily  recognize  from  the  appearance  of  the  sparks  which 
pole  is  negative  and  which  is  positive. 

If  sparks  about  four  inches  long  are  allowed  to  pass,  it  will 
be  noticed  that  at  one  terminal  they  seem  to  proceed  from 
a  point  or  comparatively  small  area  and  spread  out  and  strike 
the  other  ball  at  a  number  of  points  more  widely  separated 
The  former  is  the  positive  and  the  latter  the  negative  pole. 


CHAPTER  V. 
FLUOROSCOPY. 

X-RAY  examinations  can  be  made  with  the  fluorescent 
screen  much  more  easily  and  quickly  and  cheaply  than  with 
radiographs.  For  examinations  of  the  thorax  the  use  of  the 
fluoroscope  has  the  great  advantage  that  the  movements  of 
respiration  do  not  interfere,  as  is  the  case  in  making  radio- 
graphs of  these  parts.  Another  advantage  is  that  the  parts 
under  examination  may  be  examined  from  a  great  many  different 
points  of  view.  It  should  be  remembered,  however,  that  the 
fluoroscopic  picture  will  never  be  so  accurate  and  reliable  as 
the  radiograph,  and  that  satisfactory  radiographs  may  be 
obtained  of  many  parts  of  the  body  where  fluoroscopic  examina- 
tions are  of  no  value.  Moreover,  in  certain  cases  the  fluoro- 
scopic examination  may  be  misleading. 

Limitations  of  Fluoroscopic  Examinations. — In  partial  frac- 
tures, or  even  complete  fractures  where  there  is  little  or  no 
displacement,  the  fluoroscope  usually  fails  to  show  the  con- 
dition, but  a  good  radiograph  almost  invariably  reveals  such 
conditions.  Sometimes  a  foreign  body  which  cannot  be  shown 
by  the  fluoroscope  may  be  very  easily  found  and  located  with 
the  radiograph.  Fragments  of  fine  needles  or  small  pieces  of 
glass  may  not  be  located  with  a  fluoroscope,  but  are  very 
readily  found  with  the  photographic  plate.  In  a  case  of  a 
bullet  wound  from  a  toy  pistol  held  very  close  to  the  skin 
the  fluoroscope  showed  the  bullet  plainly  enough,  but  the 
radiograph  showed,  in  addition,  pieces  of  wadding  which  were 
carried  into  the  wound,  and  which  were  not  shown  by  the 
fluoroscope.  In  cases  of  fracture,  dislocation,  and  foreign  sub- 
stances in  the  body  it  will  usually  be  advisable  to  supplement 
the  fluoroscopic  examination  by  at  least  one  radiograph. 

Apparatus  for  Fluoroscopy. — For  the  purpose  of  fluoroscopic 
examinations  there  is  not  much  room  for  choice  between  the 

109 


110  FLUOROSCOPY. 

induction  coil  and  the  static  machine.  If  the  coil  is  used,  it 
is  advisable  to  employ  an  interrupter  which  may  give  not 
less  than  20  to  30  breaks  per  second  in  order  to  obtain  a  steady 
illumination  of  the  screen.  The  steady  illumination  of  the  tube 
which  is  produced  by  the  static  machine  is  especial!}'  adapted 
for  fluoroscopic  work.  Fluoroscopic  examinations  require  ordin- 
arily much  longer  exposures  than  are  necessary  for  making 
radiographs.  A  tube  which  may  be  operated  by  a  powerful 
coil  for  a  few  seconds  with  safety  may  become  overheated 
or  rendered  useless  if  the  same  degree  of  excitation  is  prolonged 
for  a  sufficient  length  of  time  to  make  a  careful  fluoroscopic 
examination.  With  a  static  machine  there  is  much  less  need 
for  watching  the  tubes  to  guard  against  overheating,  and  most 
tubes  will  have  a  much  longer  life  than  if  excited  by  a  coil. 

For  fluoroscopic  examinations  of  almost  every  part  of  the 
body  it  is  well  to  choose  tubes  of  considerably  higher  pene- 
tration than  would  be  best  for  making  radiographs  of  the  same 
part.  It  is,  of  course,  a  great  advantage  to  be  able  to  adjust 
the  penetration  of  a  tube  so  as  to  bring  out  most  clearly  the 
part  under  examination.  The  tubes  with  vacuum  regulators 
are  very  desirable  for  this  work. 

Series  Spark  Gap. — It  has  been  noticed  that  the  character 
of  the  x-rays  delivered  by  a  tube  may  be  varied  by  introducing 
an  adjustable  spark  gap  in  series  with  it.  The  effect  of  this 
spark  gap  varies  with  different  tubes.  With  some  tubes  an 
increase  in  penetration  is  produced  when  a  spark  gap  is  intro- 
duced on  the  positive  side,  while  in  others  the  same  effect  is 
obtained  writh  the  spark  gap  on  the  negative  side.  In  others 
the  effect  is  the  same  in  either  position  of  the  spark  gap. 

A  very  efficient  series  gap  arrangement  is  that  of  Dr.  Williams, 
which  is  shown  in  figure  53,  the  essential  part  of  which  consists 
of  two  rows  of  brass  balls  mounted  a  short  distance  apart  on 
an  insulating  support  provided  with  a  sliding  rod  by  means 
of  which  any  number  of  gaps  between  the  balls  may  be  put 
in  circuit.  The  brass  balls  are  about  f  of  an  inch  in  diameter 
and  the  interval  separating  them  is  about  ^  of  an  inch,  about 
15  to  18  balls  being  used  in  each  row.  One  of  these  arrange- 
ments is  connected  to  each  terminal  of  the  exciting  apparatus., 


SERIES    SPARK   GAP. 


Ill 


and  the  sliding  rod  by  which  adjustment  is  made  may  be  mani- 
pulated by  means  of  cords  with  handles  extending  down  where 
they  can  be  reached  by  the  observer  while  using  the  fluoro- 
scope.  In  operation  the  discharge  passes  as  a  spark  from  each 
ball  to  the  next  one  through  an  air  gap  of  about  £  of  an  inch. 
By  varying  number  of  balls  in  circuit  a  very  wide,  and  at  the 


Fig.  53. — Williams  series  spark  gap. 

same  time  delicate,  adjustment  of  the  penetration  may  be 
secured.  The  widest  range  of  regulation  will  be  obtained  when 
the  vacuum  of  the  tube  is  very  low,  so  low  that  it  is  practically 
worthless  when  excited  in  the  ordinary  manner.  The  arrange- 
ment is  much  more  effective  with  static  machines  than  with 
induction  coils.  With  the  induction  coil  it  is  necessary  to 


cz:::: 


Fig.  54. — Wilkinson's  spark  gap. 

connect  Leyden  jars  in  the  circuit  across  the  terminals  in  order 
to  obtain  the  best  effect  of  the  spark  gaps. 

No  adequate  explanation  has  been  given  for  the  penetration 
effects  produced  by  this  apparatus.  In  the  hands  of  Dr.  Wil- 
liams it  has  been  used  with  splendid  success  in  fluoroscopic 
examinations  of  the  thorax,  and  also  in  radiographic  work. 

A  serious  objection  to  its  use  is  the  very  disagreeable  noise 


112  FLUOROSCOPY. 

produced  by  the  sparks  passing  across  the  gap.  Another  dis- 
advantage is  that  it  requires  an  exciting  apparatus  capable  of 
delivering  much  longer  sparks  than  are  necessary  with  tubes 
of  proper  vacuum. 

A  modification  of  the  Williams  spark  gap,  which  is  somewhat 
simpler  in  construction,  and  which  is  arranged  to  be  attached 
to  the  tube-holder,  has  been  devised  by  Mr.  Wilkinson,  and 
is  shown  in  figure  54. 

Fluoroscopes  and  Fluorescent  Screens. — Although  there  are 
a  great  many  salts  which  fluoresce  under  the  action  of  the 
#-ray,  there  are  only  two  which  have  been  extensively  used 
in  fluorescent  screens  for  practical  work.  These  are  barium- 
platino-cyanide  and  calcium  tungstate.  The  barium  salt  gives 
a  yellowish-green  fluorescence  of  great  brilliancy,  and  is  the 
one  preferred  for  fluoroscopes.  The  tungstate  of  calcium  gives 
a  bluish-white  fluorescence,  not  so  brilliant  as  that  of  the 
barium  salt,  but  which,  on  account  of  its  color,  has  greater 
action  on  photographic  plates,  and  is  therefore  used  in  intensi- 
fying screens  for  radiographic  work.  Tungstate  screens  are 
used  also  in  fluoroscopes,  and  are  preferred  by  some  operators. 
This  preference  may  in  some  cases  be  due  to  a  partial  color- 
blindness. 

The  ordinary  fluorescent  screen  consists  of  a  piece  of  card- 
board coated  on  one  side  with  a  thin  layer  of  crystals  of  the 
fluorescent  material,  and  supported  in  a  wooden  frame.  Such 
a  fluorescent  screen  is  convenient  where  demonstrations  are  to 
be  made  to  a  large  number  of  people  at  once.  Such  screens 
must  be  used  in  a  darkened  room,  and  the  light  produced 
by  the  fluorescence  of  the  glass  of  the  tube  should  be  cut  off 
by  covering  it  with  a  piece  of  black  silk  cloth  or  enclosing 
it  in  a  box. 

A  fluoroscope  consists  of  such  a  screen  mounted  in  the  end 
of  a  box  or  hood,  one  end  of  which  may  be  fitted  closely  to 
the  eyes,  and  which  shuts  out  any  external  light  from  the 
screen.  In  the  ordinary  fluoroscope  the  hood  is  made  of  thin 
wood  covered  with  cloth,  as  shown  in  figure  55.  Some  fluoro- 
scopes have  a  hood  made  of  a  leather  bellows  so  that  the  dis- 
tance between  the  screen  and  the  eye  of  the  observer  may 


FLUOROSCOPES  AND  FLUORESCENT  SCREENS. 


113 


be  adjusted.  This  is,  of  course,  a  convenience,  though  in 
practice  not  an  important  one.  In  the  ordinary  fluoroscope 
the  pasteboard  back  of  the  fluorescent  screen  is  very  liable 
to  mechanical  injury;  and  when  it  is  used  in  examinations  of 
injuries  where  there  are  open  wounds  or  pus,  it  is  very  liable  to 
absorb  moisture  and  become  damaged  in  this  way.  For  such 
work  as  this  it  is  very  desirable  to  cover  the  screen  with  a 
smooth  non-absorbent  material  which  can  be  readily  cleansed. 
This  protects  the  screen  against  injury  and  also  lessens  the 
danger  of  carrying  infection  from  one  patient  to  another. 
Sheet  celluloid  ^  of  an  inch  thick  answers  very  well  for  this 
purpose.  It  offers  considerable  protection  against  mechanical 
injury  and  it  can  be  easily 
cleansed  and  sterilized.  It 
offers  so  little  obstruction 
to  the  x-rays  that  it  does 
not  impair  the  efficiency 
of  the  fluoroscope.  Con- 
siderations of  cleanliness 
suggest  also  the  use  of 
some  non-absorbent  ma-  ; 
terial  instead  of  cloth  for 

Covering  the  hood  of  the     Fig.  55.— Fluoroscope  with  removable  screen. 

fluoroscope. 

Fluoroscopes  with  hoods  of  hard-rubber  are  better  in  this 
respect.  Sometimes  the  face  of  the  fluoroscope  screen  is  covered 
with  a  thick  plate  of  glass.  This  arrangement  has  several 
advantages.  It  protects  the  crystals  from  dust,  and  to  a 
certain  extent  it  prevents  them  from  drying  out,  especially 
if  the  back  of  the  screen  is  covered  with  celluloid.  Finally, 
to  a  great  extent  it  protects  the  observer  against  the  x-rays 
which  pass  through  the  screen,  although  it  does  not  obscure 
the  light  due  to  the  fluorescence.  It  has  the  disadvantage 
of  making  the  screen  heavy  and  clumsy. 

In  order  to  prevent  the  secondary  rays  from  affecting  the 
screen,  and  possibly  masking  the  useful  fluorescence,  it  has 
been  suggested  to  line  the  hood  with  sheet-metal.  This  result 


114 


FLUOROSCOPY. 


is,  of  course,  accomplished  effectively  by  the  use  of  a  heavy 
lead  glass  in  direct  contact  with  the  screen. 

It  has  been  noticed  that  fluorescent  screens  deteriorate  with 
age.  This  may  be  due  partly  to  loss  of  water  of  crystallization, 
and  it  is  said  to  be  due  also  to  chemical  changes  which  are 
produced  by  the  action  of  the  powerful  x-rays.  Screens  should 
never  be  left  near  a  steam  radiator,  or  in  any  place  where  they 
are  subjected  to  hot  dry  air.  It  is  also  recommended  that 
they  be  kept,  when  not  in  use,  in  metal  cases  to  protect  them 


Pig.  5fi. — Rack  for  supporting  tubes,  fluoroscopes,  etc. 

from  the  action  of  the  x-rays.  The  ordinary  fluoroscope  when 
not  in  use  should  be  suspended  with  the  open  end  down  to 
prevent  collection  of  dust  upon  the  screen.  A  convenient  rack 
for  supporting  a  fluoroscope  in  this  manner  is  shown  in  figure  56. 
The  barium  screen  when  it  is  new  has  a  greenish-yellow 
color,  but  after  a  while  the  greenish  tinge  disappears  and  the 
color  becomes  a  light  canary  yellow.  Usually  when  this  condi- 
tion is  reached  the  screen  does  not  fluoresce  so  brilliantly  as 
when  it  is  new,  though  sometimes  this  is  not  the  case.  Different 


FLUOROSCOPES  AND  FLUORESCENT  SCREENS.       115 

screens  vary  much  in  their  keeping  qualities.  Some  of  them 
may  be  very  efficient  after  three  or  four  years'  use.  When  a 
screen  has  deteriorated,  or  become  injured  in  any  way,  it  may 
be  returned  to  the  makers,  who  will  allow  for  the  fluorescent 
material  which  it  contains. 

It  will  be  well  to  have  at  least  two  fluoroscopes  of  different 
sizes.  For  examinations  of  the  thorax  a  large  screen  not  less 
than  11  X  14  inches  is  useful  for  showing  the  whole  area.  When 
examinations  are  to  be  made  of  a  small  area,  it  will  be  found 
much  more  satisfactory  to  use  a  fluoroscope  with  a  small  screen, 
for  the  reason  that  in  such  a  case  the  illumination  of  the  screen 
beyond  the  part  under  examination  only  tends  to  dazzle  the 
eyes.  In  the  ordinary  fluoroscope  there  is  usually  a  frame 
of  wood  about  one  inch  wide  between  the  margin  of  the  screen 
and  the  edge  of  the  hood.  In  certain  situations  this  prevents 
placing  the  screen  in  the  most  convenient  position :  for  example, 
when  the  fluoroscope  is  placed  at  the  front  of  the  neck,  under 
the  lower  jaw,  the  screen  of  such  a  fluoroscope  cannot  be  placed 
as  high  as  may  be  desired.  For  such  work  as  this  it  is  therefore 
well  to  have  a  small  fluoroscope  in  which  the  fluorescent  material 
extends  quite  up  to  the  edge  of  the  hood  on  one  side  at  least. 

In  order  to  make  fluoroscopic  examinations  with  satisfaction 
it  is  necessary  to  have  the  retina  in  proper  condition.  If  one 
has  been  in  the  bright  sunlight  it  may  be  necessary  to  remain 
in  a  darkened  room  for  fifteen  to  twenty  minutes  before  the 
eyes  will  be  in  the  best  condition  for  observing  the  faint  illu- 
mination of  the  screen.  It  is  quite  likely  that  for  those  persons 
in  whom  there  is  lack  of  color  sensitiveness  for  green  the  barium 
fluoroscope  will  be  unsatisfactory.  It  is  probable  that  the 
tungstate  screen,  owing  to  the  color  of  its  fluorescence,  will 
be  more  satisfactory  for  persons  whose  eyes  are  defective  for 
either  the  green  or  the  red  colors. 

Even  the  light  from  the  tube  when  it  is  strongly  excited 
may  be  sufficient  to  reduce  the  sensitiveness  of  the  eye  for 
the  picture  on  the  fluorescent  screen.  As  has  been  mentioned 
before,  this  may  be  prevented  by  covering  the  tube  with  black 
silk  cloth,  or  by  enclosing  it  in  a  box. 

Fluoroscopic   examinations   should    always   be   made    in   a 


116  FLUOROSCOPY. 

darkened  room.  It  is  convenient  to  have  near  the  operator's 
hand  a  switch  for  controlling  the  electric  lights  of  the  room, 
and  to  have  these  lights  so  arranged  that  they  may  be  run 
at  a  very  low  power  for  the  very  slight  illumination  which 
is  necessary  while  examinations  are  being  made.  Instead  of 
this,  a  single  ruby  lamp  may  be  arranged  for  this  purpose. 

In  order  to  prevent  the  light  of  the  tube  from  disturbing 
the  eyes  of  the  observer,  and  at  the  same  time  prevent  the 
projection  of  the  rays  in  other  directions  than  are  needed, 
Dr.  Williams  encloses  the  tube  in  a  wooden  box  lined  with 
several  layers  of  white  lead  paint,  and  closed  in  front  with  a 
series  of  diaphragms,  which  may  be  adjusted  to  give  different 
amounts  of  rays  according  to  the  area  which  it  is  desired  to 
illuminate.  This  arrangement  is  very  effective,  but  it  is  some- 
what clumsy  and  most  operators  prefer  to  use  the  tube  in 
the  ordinary  manner. 

Adjustable  Diaphragms. — Sometimes  an  adjustable  diaphragm, 
is  placed  in  front  of  the  tube  to  reduce  the  rays  to  the  area 
which  it  is  desired  to  illuminate.  Such  a  diaphragm,  made 
by  Siemens  &  Halske,  is  readily  attached  to  the  tube-holder. 

Guarding  against  Over-exposure. — In  making  fluoroscopic 
examinations  it  will  be  found  that  nearly  always  the  patient 
is  subjected  to  very  much  longer  exposure  than  is  necessary 
for  making  several  radiographs.  Moreover,  the  observer's  eyes 
are  covered  with  the  fluoroscope,  and  he  may  move  the  subject 
closer  and  closer  to  the  tube  in  order  to  get  a  better  view. 
Thus  the  patient  is  liable  to  be  subjected  not  only  to  longer 
exposures  than  are  safe,  but  to  closer  proximity  to  the  tube 
than  is  advisable.  The  risk  of  injury  is  therefore  much  greater 
than  in  radiographic  exposures.  As  a  matter  of  fact,  most  of 
the  severe  burns  which  have  led  to  damage  suits  have  been 
produced  by  fluoroscopic  examinations.  In  order  to  prevent 
this  unpleasant  consequence  it  is  well  to  keep  account  of  the 
time  during  which  the  patient  is  exposed,  'and  not  to  allow 
this  to  exceed  ten  or  fifteen  minutes,  with  the  tube  not  nearer 
than  12  or  15  inches  from  the  skin.  A  screen  of  thin  cardboard 
or  wood  may  be  interposed  between  the  tube  and  the  patient 
in  order  to  prevent  getting  too  close  to  the  tube  while  the 


SCREENS  FOR  PREVENTING  BURNS.  117 

observer's  eyes  are  covered  by  the  fluoroscope.  The  practice 
of  allowing  a  large  number  of  persons  to  examine  a  subject 
one  after  another  is  dangerous  unless  attention  be  paid  to  the 
matter  of  time  of  exposure  and  distance  from  the  tube. 

Screens  for  Preventing  Burns. — It  has  been  alleged  that  burns 
"may  be  prevented  by  interposing  between  the  tube  and  the 
patient  a  thin  metallic  screen  connected  by  a  wire  to  the  earth. 
Experience  has  proved  that  burns  may  be  produced  by  rays 
which  pass  through  an  aluminum  sheet,  and  that  the  ground 
connection  is  of  no  value.  It  can  scarcely  be  doubted,  how- 
ever, that  some  of  the  rays  which  are  most  easily  absorbed, 
and  which  are  most  likely  to  produce  effects  upon  the  skin, 
will  be  absorbed  by  a  thin  sheet  of  aluminum;  and  that  the 
rays  which  are  most  useful  in  making  fluoroscopic  examinations 
will  be  very  little  obstructed  by  it.  The  use  of  such  a  screen 
is,  in  most  cases,  an  unnecessary  precaution,  but  severe  x-ray 
burns  are  very  unpleasant,  and  it  may  be  well  enough  to  keep 
on  the  safe  side.  Dr.  Williams  uses  for  this  purpose  a  thin 
sheet  of  aluminum  in  front  of  the  diaphragm  of  his  box  for 
holding  the  tubes.  It  is  quite  likely  that  such  a  screen  absorbs 
more  of  the  low  penetration  rays,  which  are  more  active  in 
causing  burns  than  of  the  higher  penetration  rays,  which  are 
useful  in  fluoroscopic  examinations. 

Importance  of  Proper  Relation  of  Fluoroscope,  Tube,  and 
Patient. — The  most  satisfactory  fluoroscopic  pictures  will  be 
obtained  when  the  part  under  examination  is  brought  as  close 
as  possible  to  the  fluoroscopic  screen  in  order  to  reduce  the 
distortion  of  the  shadows  to  a  minimum.  It  is  also  important 
that  the  rays  should  fall  upon  the  screen  in  a  direction  as  nearly 
as  possible  at  right  angles  to  its  plane.  Care  must  be  taken, 
therefore,  to  keep  the  fluoroscope  directed  toward  the  target 
of  the  tube — a  matter  which  is  often  overlooked.  In  order  to 
maintain  the  fluoroscope  in  proper  relation  to  the  tube  it  is 
sometimes  mounted  on  an  arm  which  is  fixed  to  the  tube-holder, 
and  arranged  so  as  to  allow  the  movement  of  fluoroscope  and 
tube  together. 

Fluoroscopic  Examinations  of  Head,  Face,  and  Neck. — In 
fluoroscopic  examinations  of  the  head  it  will  be  invariably 


118  FLUOROSCOPY. 

necessary  to  use  a  tube  of  high  penetration,  for  the  reason 
that  both  the  skull  and  the  brain  offer  considerable  obstruction 
to  the  rays.  The  thickness  of  the  skull  varies  greatly  in  different 
individuals,  and  this  must  be  taken  into  account  in  inter- 
preting the  shadows. 

In  this  region  it  is  well  to  be  especially  careful  to  guard 
against  over-exposure  and  against  getting  too  close  to  the  tube. 
Even  though  no  burns  occur,  it  may  happen  that  the  hair  on 
one  side  of  the  head  will  fall  out.  In  examining  the  face  and 
neck  the  head  can  be  protected  by  wrapping  it  with  lead-foil 
about  -^  of  an  inch  thick. 

Examinations  of  the  face  and  neck  in  a  direction  from  side 
to  side  wrill  be  quite  easy.  The  cervical  vertebra?  will  be  dimly 
outlined,  the  hyoid  bone  and  cartilages  of  the  larynx  will  be 
plainly  seen,  with  sometimes  a  light  streak  which  marks  the 
course  of  the  trachea.  A  foreign  body,  such  as  a  pin  or  a 
piece  of  metal,  in  the  pharynx  or  upper  part  of  the  esophagus 
may  be  readily  seen.  A  view  from  side  to  side  gives  us,  of 
course,  the  antero-posterior  relations  of  the  object.  In  order 
to  determine  the  position  fully  it  will  be  necessary  to  make 
examinations  in  the  sagittal  direction.  This  is  not  so  easy, 
for  the  reason  that  the  lower  jaw  prevents  us  from  placing 
the  fluoroscope  in  the  best  position. 

Shoulder. — It  is,  of  course,  impossible  to  obtain  a  shadow  of 
the  shoulder  from  side  to  side,  but  some  idea  of  the  antero- 
posterior  relations  may  be  obtained  by  shifting  the  patient 
in  a  somewhat  diagonal  position.  In  most  cases  it  will  be 
found  better  to  make  examinations  in  the  sagittal  direction, 
both  from  back  and  front  of  the  patient. 

Extremities. — Fluoroscopic  examinations  of  the  extremities 
may  be  made  from  many  points  of  view.  To  make  such  ex- 
aminations the  first  step  is  to  place  the  patient  in  a  position 
which  will  be  comfortable  and  which  will  at  the  same  time 
allow  of  the  proper  disposition  of  the  tube  and  fluoroscope. 
This  will  depend  so  much  upon  the  nature  of  the  injury  that 
no  definite  direction  can  be  given  here,  but  suitable  positions 
will  readily  suggest  themselves  to  any  one  who  is  to  make 
such  examinations. 


FLUOROSCOPIC   EXAMINATIONS   OF   THE    THORAX.  119 

Thorax. — One  of  the  most  useful  fields  for  fluoroscopic  ex- 
aminations is  in  examinations  of  the  thorax  for  lesions  of  the 
heart,  lungs,  and  pleural  sac.  Much  may  be  learned  by  observ- 
ing the  movements  of  these  parts,  the  excursions  of  the  dia- 
phragm on  either  side,  the  pulsations  of  the  heart,  and  the 
pulsations  of  aneurisms. 

Thoracic  organs  exhibit  considerable  displacements  by  gravity 
in  different  positions  of  the  body,  and  examinations  of  this 
region  will  therefore  be  made  with  the  patient  in  a  sitting 
or  standing  posture.  For  the  comfort  of  the  patient  it  will 
be  well  to  allow  him  to  sit  on  a  stool  or  chair  with  a  back  of 
canvas  or  other  material  which  offers  little  obstruction  to  the 
rays.  The  distance  between  the  tube  and  the  patient  in  these 
examinations  will  be  determined  partly  by  the  power  of  the 
x-rays  and  partly  by  the  thickness  of  the  subject.  In  order 
to  avoid  undue  distortion  of  the  shadow  it  will  be  well  to  have 
the  distance  between  the  tube  and  the  patient  not  less  than 
two  feet.  It  has  been  shown  by  Dr.  Cowl  that  at  this  dis- 
tance the  amount  of  distortion  is  not  sufficient  to  cause  serious 
error. 

It  is  important  in  making  examinations  of  this  region  to 
have  a  standard  position  for  the  tube  with  reference  to  the 
patient.  A  good  position  is  to  place  the  target  of  the  tube 
opposite  the  median  line  at  the  level  of  the  fourth  dorsal  ver- 
tebrae. In  many  cases  it  will  be  necessary  to  examine  the 
patient  from  other  positions  than  the  standard  ;  for  example, 
the  determination  of  the  presence  of  aneurism  of  the  aorta. 
The  distinctive  sign  of  aneurism  is  the  pulsation,  which  can 
almost  invariably  be  observed. 

The  interpretation  of  the  fluoroscopic  pictures  of  this  region 
is  a  matter  which  requires  not  only  thorough  knowledge  of 
the  pathology  of  the  thoracic  organs,  but  considerable  practice 
in  the  use  of  the  x-rays.  Advice  and  help  on  these  points  will 
be  found  in  the  works  of  Holzknecht,  Von  Ziemssen  and  Rieder, 
Williams,  BeClere,  and  others. 

In  order  to  avoid  the  distortion  of  the  shadow  picture  in 
the  fluoroscope,  and  to  enable  accurate  measurements  of  the 
size  of  the  heart  and  other  organs  which  may  be  traced,  Dr. 


120 


FLUOROSCOPY. 


Moritz  has  devised  an  appliance  known  as  the  diagraph.  In 
this  apparatus  a  large  fluorescent  screen,  covered  with  a  sheet 
of  celluloid  or  glass,  is  held  in  permanent  position  in  front 
of  the  patient.  A  movable  U-shaped  arm,  one  end  of  which 
carries  the  x-ray  tube  and  the  other  carrying  a  pencil,  is  arranged 
so  that  the  pencil  may  be  moved  over  the  area  of  the  screen, 
and  trace  an  outline  on  the  celluloid  or  glass.  Before  using 
the  apparatus  the  tube  and  the  pencil  are  adjusted  so  that  a 
line  connecting  the  tip  of  the  pencil  with  the  source  of  the 


Fig.  57. — Apparatus  for  orthographic  projection  of  ar-ray  shadows  on  fluorescent 

screen. 

x-ray  passes  always  through  the  screen  in  a  direction  per- 
pendicular to  it.  The  tube  follows  the  movements  of  the 
pencil,  and  a  tracing  may  be  made  of  the  heart  or  diaphragm, 
for  example,  which  will  therefore  be  free  from  distortion. 

Dr.  Grunmach  has  designed  a  modification  of  this  apparatus 
in  which  the  screen  moves  with  the  pencil,  and  the  tracing 
is  made  upon  a  piece  of  paper  which  is  between  the  screen 
and  the  patient.  Several  other  workers  have  designed  machines 
of  this  sort  which  accomplish  practically  the  same  results. 
Although  it  has  been  shown  that  in  measurements  of  the  heart 


LOCATION  OF  FOREIGN  BODIES    WITH  THE  FLUOROSCOPE.    121 

the  distortion  is  slight  when  the  distance  between  tube  and 
screen  exceeds  2  to  3  feet,  it  is  fair  to  say  that  the  advantage 
of  securing  absolutely  orthographic  projection  upon  the  screen 
is  well  worth  considering,  and  will  be  of  especial  advantage 
with  a  rather  weak  exciting  apparatus  when  the  tube  must 
be  brought  close  to  the  patient.  A  convenient  apparatus  of 
this  sort,  made  by  the  Allgemeine  Elektricitats-Gesellschaft,  is 
shown  in  figures  57  and  58. 


Fig.  58. — Apparatus  for  orthographic  projection  of  x-ray  shadows  on  fluorescent 

screen. 

Abdomen  and  Pelvis. — Below  the  diaphragm  the  fluoroscope 
is  of  little  use,  and  is  seldom  employed  except  in  cases  of  foreign 
metallic  bodies  in  the  alimentary  tract,  or  bullet  wounds,  etc. 

Location  of  Foreign  Bodies  with  the  Fluoroscope. — The  loca- 
tion of  foreign  substances  in  the  body  cannot  be  accomplished 
with  as  much  certainty  with  the  fluoroscope  as  with  the  radio- 
graph, but  on  account  of  the  saving  of  time  incident  to  its 
use  the  fluoroscope  is  often  preferable.  The  common  method 


122 


FLUOROSCOPY. 


of  marking  the  position  of  a  foreign  body  is  to  observe  it  from 
several  different  positions,  and  mark  on  the  skin  points  corre- 
sponding to  different  diameters  passing  through  the  object.  In 
this  way  location  accurate  enough  for  surgical  purposes  may 
be  made.  For  convenience  in  marking  the  ends  of  the  diameters 
passing  through  the  object  I  have  used  a  sort  of  caliper  arrange- 
ment, shown  in  figure  59.  The  ends  of  the  two  arms  shown 
carry  metal  pieces  which  when  superim- 
posed give  the  shadow  of  a  cross.  The 
hinge  with  the  handle  enables  the  two 
points  to  be  separated  and  adjusted  at 
various  distances  apart,  so  that  an  arm 
or  a  leg,  for  example,  may  be  enclosed 
between  them.  The}''  are  then  moved 
until  the  shadow  in  the  fluoroscope  shows 
a  cross  with  the  object  at  the  intersection 
of  the  two  lines  of  the  cross.  The  two 
points  on  the  opposite  sides  of  the  limb 
are  then  marked  with  a  skin  pencil,  silver 
nitrate,  or  iodine.  If  the  pencil  is  used, 
it  may  be  necessary  to  make  a  scratch  on 
the  skin,  but  marks  with  iodine  or  caustic 
will  remain  after  the  skin  is  cleansed  for  a 
surgical  operation. 

Shenton's     Method. — When    a    foreign 
body  can  be  seen  best  in  only  one  direc- 
tion,— as  will   be  the  case,   for  example, 
with   a  needle  imbedded   in  the  palm  of 
the  hand  or  sole  of  the  foot, — it   is  not 
easy  to  locate  it  by  taking  observations  in 
a  lateral  direction.     For  such  cases  as  this 
the  method  devised  by  Mr.  Shenton,  of  Guy's  Hospital,  London, 
is  very  convenient.     Shenton's  description  of  this  method  is  as 
follows : 

"The  surface  of  the  palm  of  the  hand,  for  example,  is  held 
in  direct  contact  with  the  screen,  seeing  that  the  screen  and 
anode  in  the  tube  are  as  nearly  parallel  as  possible.  When  the 
needle  and  bones  are  seen  distinctly,  sway  the  screen  and  hand 


Fig.  59. — Caliper  for 
locating  foreign  bodies 
with  the  fluoroscope. 
(The  straight  arm  is 
held  against  the  fluo- 
rescent screen.) 


SHENTON'S  METHOD.  123 

from  side  to  side  and  note  the  change  in  relation  of  bones  and 
needle.  It  is  evident  that  the  image  of  whichever  is  furthest 
from  you  and  from  the  surface  of  the  screen  will  move  the 
faster.  If  the  needle  moves  across  the  bones,  its  position  is 
deeper  than  the  bone;  if  bones  move  across  the  needle,  the 
latter 's  position  must  be  between  the  surface  of  the  screen 
and  bone. 

"Should  the  needle  appear  stationary,  place  a  pointer  against 
this  image  on  the  screen  and  ascertain  whether  it  moved  a 
little  or  not  at  all.  Verify  these  results  by  reversing  the  hand 
and  repeating  the  marioeuvers.  A  little  practice  enables  one 
to  give  as  near  an  estimate  of  the  needle's  real  depth  as  any 
surgeon  could  require,  and  such  suggestions  as  'just  beneath 
the  skin  of  the  palm,'  'lower  end  between  bones,'  'upper  end 
|  of  an  inch  between  the  skin  of  the  back  of  the  hand,'  are 
in  my  experience  sufficient  for  any  operator. 

"The  needle's  depth  being  ascertained,  it  only  remains  to 
find  its  position  in  the  horizontal  planes — a  task  which  presents 
few  difficulties.  When  found,  this  position  should  be  marked 
upon  the  skin.  The  advantages  of  this  method  are  its  rapidity 
of  performance,  the  process  taking  but  a  few  seconds,  and  the 
economy  of  the  material,  both  photographic  and  electrical. 

"For  localization  in  other  parts  of  the  body  and  for  photo- 
graphically recording  results  I  have  constructed  an  instrument 
which  in  principle  is  the  same  as  the  method  just  described, 
save  that  the  tube  is  swayed  while  the  part  viewed  is  held 
in  position  by  bands  and  tension  springs.  The  tube  is  moved 
by  the  observer  from  his  side  of  the  screen,  the  distance  it 
travels  being  regulated  by  sliding  steps.  A  fine  vertical  wire 
is  stretched  in  the  center  of,  and  in  contact  with,  the  screen. 
The  image  of  the  foreign  body  is  to  correspond  with  this  line 
when  the  tube  is  in  the  mid-position.  Upon  moving  the  tube 
from  the  extreme  right  to  the  extreme  left,  the  image  of  the 
foreign  body  on  the  screen  is  seen  to  pass  from  left  to  right. 
Its  relative  rate  of  traveling  compared  with  the  same  portion 
of  bone  is  noted  as  before. 

"For  accurate  measurements  the  true  position  assumed  by 
the  foreign  body  is  marked  by  a  pencil  on  a  celluloid  film  in 


124  FLUOROSCOPY. 

contact  with  the  screen.  This  measurement  being  secured,  the 
distance  the  tube  travels,  and  the  distance  from  the  mid-point 
of  the  line  adjoining  the  two  extreme  positions  of  the  tube, 
must  be  ascertained.  A  simple  rule  of  three  will  now  give 
the  distance  of  the  object  sought  from  the  screen." 

Stereo-fluoroscopy. — It  was  shown  by  Elihu  Thomson  in 
1896  that  two  radiographs  made  by  displacing  the  tube  through 
a  distance  about  equal  to  that  between  the  eyes,  when  viewed 
through  a  stereoscope,  would  give  the  effect  of  relief.  Mackenzie 
Davidson  in  1897  succeeded  in  obtaining  stereoscopic  pictures 
on  the  fluorescent  screen.  He  has  obtained  this  result  in  the 
following  way: 

He  placed  two  x-ray  tubes  a  short  distance  apart,  and  excited 
them  alternately  by  an  induction  coil.  In  the  field  of  these 
x-ray  tubes  he  places  a  stationary  fluorescent  screen,  in  front 
of  which  are  the  two  sight-holes  having  a  shutter  actuated 
synchronously  with  the  changing  of  the  excitation  of  the  two 
tubes.  He  has  described  two  methods  of  obtaining  the  alternate 
excitation  of  the  two  tubes.  In  one  of  these  he  uses  two 
induction  coils,  each  connected  to  one  of  the  tubes,  and  inter- 
rupts the  primary  circuit  of  one  coil  and  then  of  the  other. 
In  the  other  method  he  uses  one  induction  coil  and  switches 
the  secondary  discharge  of  the  coil  from  one  x-ray  tube  to 
the  other  by  a  revolving  switch  mechanism.  Synchronism 
between  the  excitation  of  the  tubes  and  the  operation  of  the 
shutter  is  obtained  by  attaching  the  interrupter,  the  switch 
mechanism  for  the  tubes,  and  the  shutter  to  the  same  shaft, 
which  is  revolved  by  an  electric  motor.  If  the  distance  between 
the  two  tubes  and  their  relation  to  the  fluoroscopic  screen 
are  properly  arranged,  a  very  beautiful  stereoscopic  effect  is 
produced,  and  the  image  seen  on  the  screen,  instead  of  appearing 
as  a  flat  shadow,  stands  out  in  full  relief  and  appears  to  be 
really  in  front  of  the  screen.  There  is,  of  course,  some  dis- 
tortion of  the  shadows,  and  such  a  stereoscopic  picture  is,  there- 
fore, not  absolutely  accurate,  but  it  is  sufficiently  so  to  be 
of  great  practical  value. 

In  December,  1901,  the  author  described  in  the  Electrical 
Review  a  modification  of  this  apparatus  which  resulted  in 


125 


STEREO-FLUOROSCOPY.  127 

somewhat  of  a  gain  in  simplicity  and  flexibility.  The  principle 
is  the  same  as  that  of  Mackenzie  Davidson,  namely,  that  of 
rapidly  alternating  pictures  and  occlusions  synchronously  of 
the  eyes  so  that  one  eye  sees  always  one  picture  and  the  other 
the  other  picture. 

These  appliances  promise  to  be  of  great  value  in  the  location 
of  foreign  bodies  and  for  fluoroscopic  examinations  in  certain 
situations  where  it  is  difficult  to  estimate  the  space  relations 
of  the  parts  in  the  ordinary  fluoroscope.  They  may  also  be 
of  great  value  in  enabling  the  surgeon  to  replace  fragments 
of  broken  bones  while  observing  them  through  the  fluoroscope. 
Up  to  the  present  time  the  mechanical  details  of  these  appli- 
ances have  not  been  sufficiently  perfected  to  make  them  available 
to  any  but  the  most  painstaking  operators. 


CHAPTER  VI. 
RADIOGRAPHY, 

DIAGNOSIS  with  the  x-ray  attains  its  greatest  perfection 
with  the  radiograph.  The  beautiful  shadow  pictures  of  the 
fluorescent  screen  do  not  approach  in  accuracy  and  delicacy 
of  detail  those  which  can  be  obtained  upon  the  photographic 
plate.  This  is  a  fact  that  is  not  generally  appreciated  by 
physicians,  who  often  content  themselves  with  a  fluoroscopic 
examination  in  cases  where  much  more  might  be  shown  by 
a  good  radiograph.  Successful  radiographic  work  requires 
greater  skill  in  the  manipulation  of  the  apparatus  than  is 
necessary  in  any  other  field  in  which  the  x-ray  is  applied.  A 
successful  radiographer  must  have  good  tubes,  efficient  appa- 
ratus, abundance  of  auxiliary  appliances,  considerable  skill  in 
the  management  of  the  photographic  plate,  and  fair  knowledge 
of  anatomy,  especially  of  osteology,  together  with  a  good 
general  idea  of  the  common  surgical  injuries.  The  art  has 
now  progressed  far  enough  so  that  the  best  results  will  not 
be  obtained  by  a  man  who  simply  knows  how  to  operate  an 
.x-ray  machine,  and  the  time  has  arrived  when  this  work  has 
become  a  specialty,  and  should  not  be  entrusted  to  the  hands 
of  hospital  orderlies,  engineers,  and  janitors 

Success  in  radiographic  work  depends  much  upon  three  fac- 
tors :  the  manipulation  of  the  exciting  apparatus,  the  successful 
control  of  the  tube,  and  the  proper  development  of  the  plate. 

Exciting  Apparatus. — Exciting  apparatus  of  considerable 
power  is  necessary  for  radiographic  work.  Either  the  induction 
coil  or  a  static  machine  may  be  used.  The  shortest  exposures 
are  possible  with  a  coil,  but  satisfactory  radiographs  of  almost 
every  part  of  the  body  may  be  obtained  under  favorable  con- 
ditions with  a  good  static  machine.  For  radiographs  of  the 
thicker  parts  of  the  body,  for  examinations  for  renal  calculi, 
etc.,  a  coil  is  very  much  to  be  preferred.  An  induction  coil 

128 


129 


DURATION    OF   EXPOSURE.  131 

not  only  makes  it  possible  to  shorten  the  exposure,  but  the 
quality  of  ray  suitable  for  this  kind  of  work  can  be  more  readily 
obtained  with  the  coil  than  with  a  static  machine.  In  radio- 
graphing those  parts  of  the  body  which  are  subjected  to  consider- 
able movement  during  respiration  it  is  very  desirable  that  the 
exposure  should  be  made  during  the  time  in  which  the  patient 
may  hold  his  breath.  The  parts  of  the  body  to  be  considered 
here  are  the  shoulder,  thorax,  and  abdomen,  and  these  are 
the  parts  of  the  body  which  are  most  difficult  to  radiograph 
with  a  static  machine. 

Duration  of  Exposure. — It  is  impossible  to  state  any  definite 
ratio  between  the  time  of  exposure  required  for  these  different 
types  of  exciting  apparatus,  for  this  will  be  a  matter  depending 
so  much  upon  the  condition  of  the  tubes  used.  A  few  men 
have  obtained  with  the  static  machine  excellent  radiographs 
of  the  extremities  with  exposures  much  shorter  than  those 
which  are  ordinarily  necessary  with  an  induction  coil.  How- 
ever, taking  the  best  exposures  that  have  been  made  with 
a  coil,  and  comparing  them  with  the  exposures  necessary  for 
the  same  subject  with  the  static  machine,  the  ratio  will  be 
between  5  to  1  and  10  to  1  in  favor  of  the  coil.  Radiographs 
of  the  hand,  for  example,  which  may  be  readily  obtained  with 
the  induction  coil  in  three  seconds,  will  require  fifteen  to  twenty 
seconds  with  a  very  good  static  machine. 

The  duration  of  the  exposure  in  radiographic  work  depends 
upon  a  great  many  factors:  the  exciting  apparatus  used,  the 
efficiency  of  the  tube,  the  thickness  of  the  part,  the  sensitiveness 
of  the  plate,  distance  of  tube  from  plate,  etc.  These  factors 
are  so  variable  that  it  is  impossible  to  give  definite  rules  for 
the  length  of  exposures.  This  is  a  matter  which  will  have 
to  be  determined  by  each  operator  by  experience  gained  with 
his  own  apparatus.  With  a  favorable  subject,  apparatus  and 
plates  of  the  best  kind,  radiographs  of  any  part  of  the  body 
may  be  made  with  exposures  of  a  few  seconds.  In  ordinary 
practice  a  majority  of  workers  find  it  necessary  to  expose  for 
the  hip-joint  five  to  fifteen  minutes,  for  the  shoulder  five  minutes, 
for  the  hand  one-half  to  one  minute,  for  the  knee  and  thighs 
two  to  three  minutes,  for  the  head  one  to  six  minutes,  for 


132  RADIOGRAPHY. 

the  elbow  and  ankle  from  one  to  three  minutes.  These  expos- 
ures are  about  the  length  ordinarily  employed  with  fair  apparatus 
and  plates,  and  without  the  use  of  intensifying  screens. 

Distance  of  Tube  from  Plate. — In  nearly  all  radiographic  work 
the  distance  between  the  tube  and  plate  *  will  be  not  less  than 
12  nor  more  than  24  inches  from  the  plate.  There  will  be 
less  distortion  of  the  shadows  and  less  risk  of  injury  to  the 
patient  with  the  tube  at  a  considerable  distance,  but  the  effect 
of  the  rays  on  the  photographic  plate  will  be  reduced  almost 
in  proportion  to  the  square  of  the  distance  between  the  target 
and  plate.  Therefore  in  radiographing  thin  parts  of  the  body, 
such  as  the  hands  and  feet,  where  the  distortion  will  be  slight, 
it  is  just  as  well  to  place  the  tube  as  near  as  12  to  15  inches. 
The  parts  nearest  the  plate  will  cast  denser  shadows  than  those 
which  are  further  away,  therefore  it  is  advisable  always  to 
bring  the  injury  you  wish  to  examine  as  near  as  possible  to 
the  plate. 

In  radiographing  the  joints  it  is  usually  desirable  to  allow 
the  rays  to  pass  between  the  articular  surfaces  so  that  the 
shadows  of  the  bones  entering  the  injured  joint  are  not  super- 
imposed. 

Clothing. — It  is  true  that  the  clothing  offers  very  little  ob- 
struction to  the  x-ray,  but  for  several  reasons  it  is  advisable 
to  have  the  parts  to  be  radiographed  uncovered,  or  at  most 
covered  only  by  a  single  layer  of  cloth.  Unless  this  is  done  it  is 
difficult  or  impossible  to  properly  place  the  tube  and  plate 
with  reference  to  the  subject.  Seams  of  clothing  and  buttons 
cast  shadows  which  may  impair  the  usefulness  of  the  radio- 
graph. Especially  is  this  so  if  we  are  trying  to  locate  a  stone 
in  the  kidney  or  a  foreign  body  in  the  intestine. 

Radiographing  Both  Sides  for  Comparison. — In  injuries  of  the 
hands  or  feet  and  other  parts  of  the  body  it  is  often  desirable 
to  show  on  the  same  plate  a  radiograph  of  the  normal  part 
on  the  other  side  of  the  body.  This  is  especially  useful  if 
the  radiograph  is  to  be  used  as  evidence  in  court. 

*  In  recording  the  position  of  the  tube  it  is  convenient  to  state  the  distance 
between  the  target  and  the  plate.  This  method  is  used  where  the  distance  of 
the  tube  is  mentioned  in  these  pages. 


BANDAGES,    SPLINTS,    PLASTER    CASTS,    ETC.  133 

Bandages,  Splints,  Plaster  Casts,  etc. — It  is,  of  course,  unwise 
to  remove  bandages  and  splints  for  the  purpose  of  making 
radiographs  in  cases  of  recent  fractures,  but  it  will  be  a  great 
help  to  the  radiographer  if  the  dressings  are  of  a  material 
which  is  not  opaque  to  the  ray,  and  if  in  bandaging  a  limb 
proper  regard  is  had  to  the  position  which  will  be  used  in  making 
radiographs.  Surgeon's  plaster  ordinarily  contains  soaps  of 
lead  or  zinc,  and  these  materials  cast  shadows.  lodoform 
dressings  also  cast  more  or  less  dense  shadows.  Rubber  drain- 
age-tubes show  in  the  radiograph,  but  they  need  not  be 
mistaken  for  anything  else.  The  ordinary  wood  splints  used 
in  cases  of  fractures  offer  no  serious  obstruction  to  the  x-rays, 
and  in  these  cases  the  usual  difficulty  is  that  the  limb  is  so  ban- 
daged it  is  impossible  to  place  the  plate  in  proper  relation  to  it. 
Radiographs  through  plaster  casts  show  enough  to  indicate 
whether  the  fragments  of  a  fracture  are  in  proper  relation  or  not. 
Longer  exposures  will  be  required  with  plaster  casts,  and  the 
radiographs  will  always  be  hazy  and  mottled  by  the  shadows  of 
the  plaster.  The  starch  dressings  which  may  sometimes  be 
used  instead  of  plaster-of-Paris  offer  very  little  obstruction  to 
the  rays. 

Diagnosis  of  Malignant  Growths. — It  is  rarely,  if  ever,  possible 
to  show  with  the  x-ray  malignant  growths  of  the  soft  parts 
of  the  body  which  are  not  readily  recognizable  by  other  means. 
For  malignant  growths  of  the  bone,  and  foci  of  necrosis  in 
them,  the  x-ray  is  a  very  valuable  aid  in  diagnosis,  but  in 
the  soft  parts  it  is  of  little  use. 

Marking  the  Skin. — In  the  location  of  needles  and  pieces  of 
metal  near  the  surface  of  the  body  it  is  often  desirable  to  show 
the  skin  in  order  to  assist  in  estimating  the  depth  of  the  object. 
This  may  be  accomplished  by  smearing  the  skin  with  oil,  and 
then  rubbing  it  with  powdered  bismuth  subnitrate.  The  rugae 
on  the  skin  of  the  palm  of  the  hand  and  sole  of  the  foot  may  be 
beautifully  shown  by  this  method.  Figure  60  shows  a  stereo- 
scopic radiograph  of  a  needle  in  the  foot  with  the  skin  of  the 
sole  treated  in  this  way. 

Tubes  for  Radiographic  Work. — For  the  most  rapid  exposures 
with  powerful  induction  coils  it  will  be  necessary  to  use  strong, 


134  RADIOGRAPHY. 

heavy  tubes  with  targets  of  thick  metal,  or  those  with  water- 
cooling  devices.  These  tubes  are  very  expensive,  and  when 
used  under  the  conditions  mentioned  above  will  have  a  very 
short  life.  The  cost  of  tubes  will  be  less  if  weaker  exciting 
currents  are  employed,  and  the  exposures  somewhat  prolonged. 
If  this  is  done,  cheaper  tubes  may  be  employed  and  they  will 
have  a  longer  life.  When  fairly  long  exposures  are  to  be  made, 
it  is  better  to  use  tubes  which  have  targets  made  entirely  of 
platinum.  With  the  most  powerful  static  machines  that  are 
made  it  will  be  possible  to  use  tubes  which  are  not  heavy 
enough  for  use  with  a  fair-sized  induction  coil. 

Definition. — It  has  already  been  mentioned  that  in  order  to 
secure  sharp  shadows  there  must  be  a  single  source  of  the 
x-ray  from  an  exceedingly  small  point.  Even  in  a  tube  which 
is  well  focused  there  may  be  comparatively  weak  sources  of 
x-ray  at  points  on  the  bulb,  and  other  places  than  the  target, 
which  will  tend  to  impair  the  sharpness  of  the  shadows. 

Secondary  Rays. — Rontgen  has  shown  that  secondary  rays 
capable  of  affecting  a  photographic  plate  are  produced  when 
the  x-rays  pass  through  air  or  through  any  other  material. 
Obviously  these  secondary  rays,  although  very  weak,  will  some- 
times be  strong  enough  to  have  an  undesirable  effect  upon 
the  plate. 

The  use  of  metal  diaphragms  and  the  placing  of  the  tube 
in  an  opaque  box  for  the  purpose  of  obtaining  sharper  shad- 
ows has  already  been  mentioned.  For  lessening  the  effect  of 
these  secondary  rays  some  operators  use  a  metallic  funnel 
between  the  tube  and  the  subject;  the  small  end  of  the  funnel, 
being  opposite  the  tube,  acts  as  a  diaphragm.  Its  walls  protect 
the  plate  from  the  secondary  rays  arising  from  surrounding 
objects.  To  protect  the  plate  from  the  secondary  rays  which 
may  reach  it  from  below  it  has  been  suggested  to  use  a  sheet 
of  metal  at  the  back  of  the  plate. 

Most  of  these  devices  are  somewhat  clumsy,  and  it  is  doubtful 
whether  they  are  of  sufficient  advantage  to  offset  the  incon- 
venience of  employing  them. 

Degree  of  Penetration. — Rays  of  low  penetration  have  the 
greatest  effect  upon  the  photographic  plate,  and  for  making 


TUBE-HOLDERS.  135 

radiographs  therefore  it  is  advisable  to  employ  a  tube  of  much 
lower  penetration  than  would  be  desirable  for  fluoroscopic 
examinations.  The  degree  of  penetration  necessary  will  be 
determined  somewhat  by  the  thickness  of  the  part  which  is 
to  be  radiographed,  and  also  by  the  structures  which  we  wish 
to  show.  When  it  is  desired  to  show  the  bones  of  the  extremi- 
ties with  as  much  contrast  as  possible,  and  to  produce  a  radio- 
graph which  shows  little  or  nothing  of  the  soft  parts,  a  tube 
of  quite  low  penetration  should  be  used,  and  the  exposure 
should  be  fairly  long.  With  a  tube  of  high  penetration  there 
will  be  less  contrast  between  the  bones  and  flesh,  and  it  will 
be  found  impossible  to  develop  the  plate  so  as  to  blot  out  the 
flesh  without  also  obscuring  the  bones.  Such  a  tube  should 
be  used  when  it  is  desired  to  show  the  soft  parts  of  the  body. 
The  exposure  should  be  short,  and  the  development  carried 
out  without  any  regard  to  the  bones. 

For  showing  the  bones  of  the  hand,  arms,  feet,  and  legs 
a  tube  having  a  resistance  equal  to  an  air  gap  of  1£  to  2£  inches 
will  usually  give  the  best  results.  For  the  thicker  parts  of 
the  body,  such  as  the  pelvis,  head,  and  shoulder,  it  will  be 
necessary  to  employ  a  tube  of  little  higher  penetration.  Most 
tubes  operate  satisfactorily  for  this  work  when  the  resistance 
is  equal  to  an  air  gap  of  about  3  or  3£  inches.  For  the  thorax 
a  somewhat  lower  penetration  is  required  than  for  the  parts 
below  the  diaphragm. 

When  it  is  desired  to  show  the  softer  parts,  tubes  of  a  resist- 
ance equal  to  an  air  gap  of  5  or  6  inches  may  be  used,  but  when 
such  tubes  are  used  care  must  be  taken  to  guard  against  the 
disturbing  effects  of  the  secondary  rays.  These  effects  will 
be  reduced  by  enclosing  the  tube  in  a  box  lined  with  white 
lead  or  by  the  use  of  diaphragms,  etc. 

Tube-holders. — The  supporting  device  for  the  tube  should 
be  firm  and  steady  in  order  to  prevent  blurring  of  the  radio- 
graph by  movements  of  the  source  of  x-ray  during  exposure. 
It  should  be  strongly  made  and  stiff  so  that  it  will  not  vibrate, 
and  it  should  have  three  legs,  not  four,  so  that  it  will  stand 
firmly  upon  an  uneven  floor.  Most  of  the  tube-holders  on  the 
market  are  far  too  slender  and  lightly  constructed,  and  are 
therefore  unsteady. 


136 


RADIOGRAPHY. 


It  will  be  necessary  to  support  the 


Fig.  63. — Tube-holder  with  adjustable  shelf 
for  supporting  photographic  plate  and  subject 
to  be  radiographed  (E.  W.  Caldwell):  a,  Clamp 
for  holding  shelf  to  vertical  rod  (shelf  may  lie 
removed);  6,  ball-joint  which  allows  shelf  to  be 
tilted  30  degrees  from  horizontal  plane ;  c,  hand- 
wheel  by  which  shelf  is  clamped  in  position; 
r/,  tube  clamp  with  perforated  strap;  e,  univer- 
sal clamp  for  wire  spreader;  /,  wire  spreader 
with  adjustable  hooks  for  wires;  g,  strap  and 
fasteners  which  may  be  attached  to  any  part 
of  the  shelf  for  holding  subject  in  position. 


tube  in  a  great  variety 
of  positions,  and  the 
tube-holder  should 
therefore  allow  of  a  wide 
range  of  adjustment  in 
position. 

There  are  a  number 
of  tube-holders  with 
which  the  tube  can  be 
held  in  proper  place  for 
radiographing  the  foot 
upon  the  floor,  or  a 
hand  upon  the  table,  or 
for  fluoroscopic  exami- 
nations of  the  head  and 
neck  of  a  tall  man.  I 
have  used  at  the  Edward 
N.  Gibbs  .Y-ray  Labora- 
tory for  some  time  the 
tube-holder  shown  in 
figure  63.  This  tube- 
holder  consists  of  an 
upright  rod  of  l|-inch 
brass  tubing  which  is 
supported  by  a  base  of 
cast  metal  having  three 
legs,  thus  giving  steady 
support.  The  arm  car- 
rying the  tube  is  ad- 
justable in  the  amount 
of  its  projection  beyond 
the  vertical  support,  and 
may  be  rotated  upon  its 
axis.  The  tube  is  held 
between  two  V-shaped 
projections  of  wood  by 
means  of  a  strap  which 
is  attached  at  one  end 


TUBE-HOLDERS. 


137 


to  a  piece  of  elastic  webbing.  The  other  end  is  perforated  with 
a  number  of  holes  to  fit  over  a  projecting  pin.  With  this  device 
an  even  tension  may  be  put  upon  tubes  of  any  size  without 
any  fear  of  straining  the  glass,  or  having  them  held  so  loosely 
that  they  will  drop  out.  The  tube  clamp  is  arranged  on  a 
curved  piece  of  wood  which  brings  the  target  of  the  tube  op- 
posite the  axis  of  the  horizontal  rod,  and  rotation  of  the  plane 
of  the  target  may  therefore  be  made  without  materially 
changing  its  position.  The  joint  of  the  tube  clamp  with  the 
horizontal  rod  enables  a  certain  amount  of  rotation  of  the 
tube  on  a  vertical  axis,  which  is  often  desirable  in  order  to 
keep  the  lead  wires  at  a  safe  dis- 
tance from  the  patient. 

For  supporting  the  hand, 
elbow,  foot,  knee,  etc.,  during 
radiographic  exposure  a  wooden 
shelf  is  arranged  to  be  clamped 
to  the  upright  rod  of  this  tube- 
holder,  and  adjusted  by  chang- 
ing the  height  as  may  be  con- 
venient. The  shelf  is  attached 
to  the  clamp  by  a  special  ball- 
and-socket  joint  which  allows  it 
to  be  tilted  in  any  direction 
through  an  angle  of  30  degrees 
for  the  purpose  of  properly  ad- 
justing  the  plane  of  the  plate 
with  reference  to  the  part  to  be  radiographed.  It  is  also 
perforated  with  a  number  of  holes  f  of  an  inch  in  diam- 
eter, and  spaced  about  one  inch  apart.  These  holes  are 
for  the  purpose  of  attaching  straps  and  other  appliances 
to  the  shelf  for  firmly  supporting  the  part,  and  prevent- 
ing movement  during  exposure. 

An  excellent  device  of  German  make  for  supporting  tubes 
and  plates  in  radiographing  various  parts  of  the  body  is 
shown  in  figures  64,  65,  and  66.  This  has  a  small  shelf  or  table 
adjustable  on  a  ball-and-socket  joint,  and  also  adjustable  in  its 
height.  The  shelf  carries  the  tube-holder,  the  details  of  which 


138 


RADIOGRAPHY. 


are  shown  fairly  well  in  the  drawing.  This  appliance  has 
the  advantage  that  the  adjustment  of  the  tube  is  not  made 
independently  of  the  adjustment  of  the  shelf;  that  is  to  say, 
the  tube  may  be  adjusted  with  proper  relation  to  the  plate 
and  then  the  plate  and  the  tube-holder  adjusted  in  proper 
position  to  the  patient,  thus  effecting  more  or  less  saving  of 
time.  Personally  I  prefer  the  form  shown  in  figure  63,  for 
the  reason  that  the  shelf  can  be  removed,  and  it  is  therefore 
better  adapted  for  use  over  a  table.  There  are  other  tube- 


Fig.  65. — Tube-holder  and  sup- 
port for  photographic  plates. 


Fig.    66. — Tube-holder    and    support    for 
photographic  plates. 


holders  in  the  market  which  answer  the  purpose  very  well. 
Any  tube-holder  which  has  a  good  firm  support,  which  holds 
the  tube  firmly  and  without  vibration,  and  which  admits  of 
considerable  range  of  adjustment,  will  be  satisf acton-. 

Tables. — For  many  radiographic  exposures  it  is  convenient 
to  have  the  patient  in  a  recumbent  position  upon  some  kind 
of  couch  or  table.  The  requirements  of  the  various  cases 
to  be  radiographed  are  so  diverse  that  it  is  almost  impossible 
to  get  a  table  which  will  be  convenient  for  every  sort  of  a 


TABLES. 


130 


case.  The  comfort  of  the  patient  suffering  from  an  injury 
which  is  to  be  radiographed  is  a  matter  which  is  often  difficult 
to  provide  for,  and  still  obtain  a  position  which  is  best  to  secure 
the  desired  relation  of  the  photographic  plate  and  tube.  Prob- 
ably nothing  has  been  made  which  will  give  more  satisfactory 
results  than  a  good  gynecological  chair  or  table.  These  chairs 
have  been  made  the  subject  of  long  and  careful  study,  and 
some  of  them  give  a  great  variety  of  adjustments.  In  selecting 


r 


Fig.  67. — Fiber-top  table  for  radiographic  work. 

a  chair  for  this  purpose  it  will  be  an  advantage  to  procure 
one  which  may  be  rotated  upon  a  vertical  axis,  and  it  is  very 
desirable  that  the  arm-rests  should  be  of  the  style  that  may 
be  removed,  so  that  when  the  chair  is  in  a  horizontal  position 
they  do  not  project  above  the  cushions  upon  which  the  plate- 
holder  will  rest. 

One  disadvantage  of  the  gynecological  chair  is  that  neither 
the  tube  nor  the  plate  can  be  placed  underneath  it,  because 


140 


RADIOGRAPHY. 


the  materials  of  which  it  is  made  will  cast  shadows.  For  work 
of  this  kind  some  operators  employ  a  canvas  stretcher  sup- 
ported on  wooden  horses.  The  canvas  offers,  of  course,  no 
appreciable  obstruction  to  the  rays,  and  therefore  allows  the 
tube  to  be  placed  underneath  the  patient  and  the  fluoroscope 
or  photographic  plate  above.  The  stretcher  is  also  of  advantage 
as  a  means  of  transporting  the  patient.  It  also  has  the  advan- 
tage that  the  plate  may  be  supported  underneath  the  stretcher, 
and  the  patient  will  then  be  saved  the  discomfort  of  lying 
upon  its  hard  surface.  A  canvas-topped  table  possesses  also 
the  same  advantages.  The  patient  may  be  placed  upon  such 


Fig.  68. — Shenton's  canvas-top  table  with  movable  tube-holder. 

a  table   and   radiographed    without   removing   him    from    the 
stretcher. 

A  number  of  makers  supply  tables  with  tops  made  of  thin 
fiber  or  other  material  which  offers  very  little  obstruction  to 
the  x-ray  and  which  is  firmer  and  stiffer  than  canvas.  These 
table  tops  are  usually  made  in  two  parts,  hinged  so  that  the 
end  supporting  the  head  may  be  raised  and  held  at  a  con- 
siderable angle  with  the  horizontal  part  of  the  table.  A  table 
of  this  type  which  is  made  by  Queen,  Willyoung,  and  others 
is  shown  in  figure  67.  Some  of  these  tables  are  provided  with 
special  devices  for  supporting  the  plate  in  various  positions 


ENVELOPES  AND  PLATE-HOLDERS. 


141 


underneath  the  table  top.  The  canvas-topped  table  made  by 
Dean,  of  London,  from  a  design  of  Mr.  Shenton's,  is  provided 
with  a  tube-holder  which  may  be  adjusted  in  various  positions 
underneath  the  table  top,  for  use  with  the  fluorescent  screen 
or  photographic  plate  placed  over  the  patient.  (See  Fig.  68.) 
Envelopes  and  Plate-holders. — There  are  many  devices  in 
use  for  guarding  the  plate  against  ordinary  light  while  the 
radiographic  exposure  is  being  made.  The  simplest  of  these 
consists  of  a  pair  of  paper  envelopes,  a  little  larger  than  the 
plate :  one  of  black  paper  and  the  other  of  orange  paper.  These 
may  usually  be  obtained  from 
the  dealer  in  photographic  ma- 
terials, and  they  are  usually  sup- 
plied with  x-ray  plates.  Some 
makers  furnish  the  plates  ready 
for  use  in  the  envelopes.  This 
practice  is  objected  to  on  the 
ground  that  chemical  sub- 
stances in  the  paper  gradually 
cause  deterioration  of  the  sensi- 
tive film  of  the  plate  if  left  in 
contact  with  it  for  some  time. 
This  objection  is  undoubtedly 
a  valid  one,  although  with  some 
papers  the  effect  is  very  slight 
indeed.  I  have  obtained  excel- 
lent results  with  plates  that 
have  been  in  the  envelopes  for 
two  months  or  more.  It  is  safer,  however,  to  buy  the 
plates  packed  in  the  boxes  in  the  usual  way  and  to  put  them 
in  envelopes  or  plate-holders  not  very  long  before  they  are  to 
be  used.  Ordinarily  the  plate  is  placed  first  in  the  black  en- 
velope, and  then  this  black  envelope  is  placed  in  the  yellow 
envelope,  keeping  the  film  side  of  the  plate  always  nearest  the 
plain  side  of  the  envelopes.  This,  of  course,  must  be  done 
in  the  dark  room.  In  practice  I  try  to  keep  constantly  on 
hand  in  the  envelopes  enough  plates  for  two  or  three  days' 
use,  and  to  use  them  rapidly  enough  so  that  they  do  not  re- 
main in  the  envelopes  longer  than  a  week. 


Fig. 


69. — Plate-holder     for 
graphic  work. 


radio- 


142 


RADIOGRAPHY. 


Several  makers  of  x-ray  apparatus  furnish  wooden-backed 
plate-holders  for  use  instead  of  the  paper  envelopes.  A  holder 
of  this  sort,  which  is  used  by  man}7  German  workers,  is  shown 
in  figure  69.  These  plate-holders  are  good,  and  they  have  the 
advantage  of  protecting  the  plate  against  breakage  by  the 
weight  of  heavy  subjects  placed  upon  them,  but  they  are  very 
bulky,  and  then  sometimes  the  thickness  of  the  wooden  backing 
is  objectionable.  I  prefer  to  use  in  most  of  my  work  the  primi- 


Fig.  70.— Plate-holder  for  plates  enclosed  in  paper  envelopes. 

tive  paper  envelopes.  For  use  with  intensifying  screens,  how- 
ever, a  plate-holder  is  more  convenient,  and  for  this  purpose 
special  plate-holders  have  been  designed. 

When  the  photographic  plate  is  placed  underneath  the  part 
to  be  radiographed  on  a  cushioned  chair  or  table,  it  may  be 
necessary  to  provide  it  with  a  stiff  backing  in  order  to  prevent 
it  from  being  broken  by  the  weight  of  the  subject.  For  this 


INTENSIFYING    SCREENS.  143 

purpose  I  have  designed  a  holder  shown  in  figure  70  which 
is  intended  to  be  used  with  plates  wrapped  in  ordinary  paper 
envelopes.  It  will  be  seen  that  this  plate-holder  consists  of 
a  board  having  a  recess  to  receive  the  plate,  and  its  edges 
rounded  and  beveled  in  order  to  produce  as  little  discomfort 
as  possible  in  contact  with  the  body.  It  is  covered  with  a 
thin  sheet  of  celluloid,  which  is  attached  at  one  edge,  and 
may  be  lifted  up  for  inserting  the  plate.  The  object  of  celluloid 
is  to  protect  the  plate  against  perspiration  or  other  excreta 
from  the  body.  When  no  plate-holder  is  used,  it  is  convenient 
to  have  sheets  of  thin  celluloid  cut  to  the  size  of  the  envelope 
holding  the  plate,  to  be  placed  between  it  and  the  patient, 
for  the  same  purpose. 

Some  workers  consider  it  essential  to  place  in  the  plate- 
holder  and  underneath  the  plate  a  sheet  of  metal  in  order 
to  protect  against  the  action  of  the  secondary  rays.  This  is 
not  a  bad  idea,  although  if  exposures  are  short  it  is  quite  un- 
necessary. A  convenient  backing  may  be  made  of  a  sheet 
of  heavy  lead-foil  about  ^  of  an  inch  thick,  cut  to  the  size 
of  the  plate. 

Intensifying  Screens. — A  very  considerable  reduction  in  the 
time  of  exposure  may  be  effected  by  placing  in  contact  with 
the  photographic  plate  a  screen  of  material  which  fluoresces 
strongly  with  an  actinic  color.  For  this  purpose  it  is  customary 
to  employ  fluorescent  screens  made  of  thin  flexible  celluloid 
coated  with  calcium  tungstate,  which  fluoresces  with  a  bluish- 
xvhite  light. 

In  using  such  a  screen  the  side  coated  with  the  crystals  is 
always  placed  in  contact  with  the  emulsion  of  the  plate  or 
film.  The  object  to  be  radiographed  may  be  placed  either 
at  the  back  of  the  plate  or  at  the  back  of  the  screen.  In  the 
one  case  the  rays  pass  directly  through  the  screen,  and  there- 
fore if  there  are  uneven  spots  in  it  they  will  cast  shadows  upon 
the  plate.  In  the  other  case  the  rays  pass  through  the  glass 
before  they  reach  the  emulsion.  The  glass  of  the  plate  is 
rather  more  opaque  than  the  screen,  and  therefore  reduces 
to  a  greater  extent  the  intensity  of  the  rays  falling  upon  the 
emulsion.  Celluloid  films,  however,  offer  practically  no  ob- 


144  RADIOGRAPHY. 

struct  ion  to  the  rays,  and  may  be  used  in  this  manner  with 
considerable  advantage. 

In  much  of  the  fastest  work  that  has  been  done  in  Germany 
films  doubly  coated  on  each  side  are  placed  between  two  such 
tungstate  screens,  thus  utilizing  to  the  greatest  extent  the 
advantages  of  the  fluorescent  screen,  and  the  multiple  coatings 
of  the  emulsion.  The  ratio  of  the  exposure  necessary  with 
a  single  intensifying  screen  and  photographic  plate  to  that 
which  is  necessary  with  the  same  plate  without  the  screen 
is  about  1  to  4  or  5.  With  a  double  film  and  two  screens  the 
exposure  may  be  reduced  to  perhaps  one-tenth  of  what  is 
necessary  under  ordinary  circumstances.  Thus  it  can  be  seen 
that  the  use  of  a  screen  offers  a  very  decided  gain  in  the  time 
of  exposure.  It  must  be  remembered,  however,  that  there  is 
marked  impairment  of  the  character  of  the  picture,  due  first 
to  the  shadow  of  the  crystals,  and,  secondly,  to  the  fact  that 
the  screens  as  they  are  made  do  not  fluoresce  uniformly,  and 
do  not  lie  flat  over  the  surface.  Hence  there  is  mottling  of 
the  negative  even  with  the  plate  between  the  screen  and  the 
tube. 

It  must  be  borne  in  mind  that  these  intensifying  screens 
phosphoresce  for  some  time  after  the  x-ray  exposure  has  ceased, 
and  therefore  it  is  important  to  keep  the  screen  in  exactly 
the  same  position  in  reference  to  the  plate  after  the  exposure 
is  made.  If  the  screen  is  placed  in  an  envelope,  it  is  likely 
to  slip  more  or  less  away  from  its  first  position  in  handling 
the  plate  after  the  exposure  is  made.  When  this  occurs,  the 
phosphorescence,  which  persists  for  some  time  afterward,  may 
cause  the  picture  to  become  blurred. 

Prevention  of  Movement  during  Exposure. — With  the  most  pow- 
erful x-rays  we  are  able  to  produce,  the  action  on  the  photographic 
plate  is  very  much  less  intense  than  that  of  ordinary  light,  and  ra- 
diographic  exposures  are  very  much  longer  than  those  ordinarily 
employed  in  camera  work.  This  is  often  a  serious  disadvantage 
because  of  the  liability  of  the  subject  to  move  during  an  ex- 
posure. The  movements  may  be  involuntary,  as  the  respiratory 
movements,  or  nervous  twitchings,  which  seem  very  liable  to 
occur  in  the  neighborhood  of  the  machine.  It  is  often  very 


PREVENTION   OF    MOVEMENT    DURING    EXPOSURE.  145 

difficult  to  keep  young  children  quiet  long  enough  to  obtain  a 
satisfactory  radiograph. 

It  is  therefore  necessary  to  take  every  precaution  to  guard 
against  movements  of  the  subject  and  consequent  blurring  of 
the  picture.  To  accomplish  this  end  it  will,  of  course,  be 
advisable  to  place  the  patient  in  the  position  which  is  as  nearly 
comfortable  as  possible.  In  order  that  he  may  not  be  startled 
when  the  exposure  begins,  it  is  a  good  idea  to  have  a  short 
rehearsal  without  the  photographic  plate,  so  that  he  may 
become  accustomed  to  the  noise  and  the  appearance  of  the 
tube. 

The  use  of  straps  for  holding  the  part  in  position  has  already 
been  mentioned.  For  the  same  purpose  it  is  very  convenient 
to  have  a  number  of  canvas  bags  partially  filled  with  sand. 
These  may  be  placed  on  top  of  the  subject,  beyond  the  limits 
of  the  plate,  and  often  assist  in  maintaining  a  fixed  position. 

With  a  healthy  adult  the  movements  of  respiration  may 
be  stopped  long  enough  to  obtain  a  radiograph  of  any  part 
of  the  body  with  the  most  powerful  apparatus.  In  order  to 
make  it  easy  for  the  patient  to  hold  his  breath,  he  may  breathe 
rapidly  and  deeply  for  a  minute  or  two  before  the  exposure 
is  made.  This  in  some  way  produces  a  condition  of  apnoea, 
and  respiration  may  be  suspended  without  discomfort  for 
thirty  to  one  hundred  seconds,  which  under  proper  conditions 
is  long  enough  to  make  a  radiograph  of  any  part  of  the  body. 

The  majority  of  operators,  however,  will  probably  not  succeed 
in  obtaining  such  short  exposures  as  this.  In  order  to  obtain 
sharp  shadows  with  longer  exposures  Dr.  Cowl  has  devised  a 
method  of  making  a  radiograph  while  the  patient  is  breathing, 
but  exposing  the  plate  only  during  the  pause  at  the  end  of 
each  expiration.  If  it  is  desired,  the  same  arrangement  may 
be  used  to  expose  for  a  very  short  time  at  any  period  of  the 
respiratory  movement,  and  thus  show  the  parts  as  though 
they  were  fixed  in  position. 

In   Cowl's   apparatus  the   induction   coil   circuit   is   opened 

and  closed  by  a  relay,  the  circuit  of  which  is  in  turn  opened 

and  closed  by  a  contact  device  clamped  against  the  thoracic 

wall  in  such  a  position  that  the  contact  is  closed  and  opened 

10 


146  RADIOGRAPHY. 

at  any  desired  point  of  the  respiratory  movement.  The  same 
result  may  be  obtained  more  or  less  imperfectly  by  opening 
and  closing  the  induction  coil  switch  by  hand  in  synchronism 
with  the  movements  of  the  thoracic  wall. 

Importance  of  Correct  Pose. — "When  we  consider  that  radio- 
graphs are  all  shadow  pictures,  it  will  be  obvious  that  it  is 
of  the  greatest  importance  to  place  the  subject,  the  tube,  and 
the  plate  in  such  relation  that  the  shadow  will  give  us  the 
information  we  desire.  Even  with  a  fair  knowledge  of  oste- 
ology it  is  more  or  less  difficult  to  know  what  kind  of  a  shadow 
the  bones  will  cast  with  the  source  of  light  in  various  positions. 
A  very  slight  change  in  the  position  of  the  source  of  the  x-ray 
will  often  make  a  great  difference  in  the  shadows  on  the  photo- 
graphic plate.  In  order  to  assist  in  determining  the  best 
position  of  the  tube  for  making  an  exposure,  and  also  for  cor- 
rectly interpreting  the  radiograph  after  it  is  made,  I  have 
found  it  very  helpful  to  study  the  shadows  produced  by  an 
articulated  skeleton  with  a  small  point  of  light,  such  as  may 
be  obtained  from  a  one  candle-power  incandescent  lamp  held 
in  the  position  of  the  x-ray  tube. 

Examining  the  Negative. — It  is  often  difficult  to  obtain  a 
really  good  print  from  an  x-ray  negative,  and  it  is  therefore 
advisable  to  learn  to  examine  the  negative,  and  not  rely  upon 
the  print.  After  one  has  become  accustomed  to  looking  at 
negatives  the}*  will  be  much  more  satisfactory  than  the  best 
print  that  can  possibly  be  made. 

Illuminating  Device. — In  order  to  examine  the  negative  to 
the  best  advantage  it  should  be  viewed  by  transmitted  light 
only;  that  is,  it  should  be  examined  in  a  room  which  is  darkened, 
and  into  which  light  is  admitted  through  the  negative.  Usually 
one  may  see  more  in  a  negative  by  holding  it  up  before  a  gas 
flame  or  an  electric  light  than  in  front  of  a  window.  The  best 
method  is  to  use  a  special  illuminating  device  which  throws 
a  very  strong  light  through  the  negative  and  cuts  off  all  that 
does  not  pass  through  it.  An  apparatus  which  I  have  devised 
for  the  Edward  X.  Gibbs  A'-ray  Laboratory  is  shown  in  figure 
71.  Several  incandescent  lamps  are  arranged  in  a  box  having 
a  white  asbestos  lining.  The  box  is  covered  by  a  sheet  of 


ILLUMINATING    DEVICE.  147 

ground  glass,  and  at  a  distance  of  an  inch  from  the  ground 


Fig.  71. — Illuminating  device  for  examining  negatives. 

glass  is  a  second  plate  of  plain  glass.     At  the  sides  of  the  box 
are  four  shades  of  material  opaque  to  light,  and  which  are 


148  RADIOGRAPHY. 

held  by  four  spring  shade  rollers.  These  shades  are  arranged 
so  that  they  overlap,  and  by  adjusting  them  at  various  points 
any  rectangular  area  up  to  the  full  size  of  the  box  may  be 
illuminated.  The  negative  resting  on  the  plain  glass  may  be 
enclosed  by  the  shades  in  such  a  way  that  no  light  from  the 
lamps  can  be  seen  except  that  which  passes  through  it.  One 
advantage  of  this  shade  roller  arrangement  over  other  devices 
which  have  frames  to  fit  different  sized  plates  is  that  it  enables 
one  to  occlude  the  light  from  any  part  of  the  plate  under  exami- 
nation and  allow  it  to  pass  only  through  the  part  which  one 
wishes  to  examine.  At  the  side  of  the  box  is  a  small  rheostat 
which  acts  as  dimmer  for  regulating  the  intensity  of  the  light 
according  to  the  density  of  the  negative  to  be  examined.  This 
dimmer  has  the  disadvantage  of  changing  the  color  of  the  light 
at  the  same  time  that  its  intensity  is  varied.  The  intensity 
of  the  light  may  be  changed  without  changing  its  color  by 
using  long  cylindrical  incandescent  lamp  bulbs,  then  sliding 
over  them  to  a  greater  or  less  extent  sleeves  of  an  opaque 
material  which  occlude  more  or  less  of  the  filaments. 

In  examining  a  very  thin  negative  it  will  sometimes  be  found 
an  advantage  to  get  away  three  or  four  feet  and  view  it  from 
a  direction  of  45  degrees  or  less  from  the  plane  of  the  plate. 

Marking  the  Negatives. — In  order  to  identify  negatives  and 
enable  them  to  be  conveniently  found  for  reference  it  will  be 
necessary  to  number  the  negatives  and  to  keep  a  more  or  less 
elaborate  system  for  recording  and  filing  them.  A  large  collec- 
tion of  negatives  arranged  for  convenient  reference  will  often 
materially  assist  in  the  proper  interpretation  of  radiographs  and 
in  determining  the  best  conditions  for  making  a  radiograph  of  a 
given  subject.  It  is  therefore  desirable  to  mark  the  negatives 
in  some  way,  and  to  have  some  good  expansible  system  for 
recording  and  filing  them. 

Negatives  may  be  marked  in  several  ways,  and  perhaps  the 
simplest  is  to  mark  on  the  film  with  an  ordinary  lead-pencil 
in  the  dark  room,  just  before  the  exposure  is  made,  the  number, 
name  of  patient,  position,  the  time  of  exposure,  or  any  other 
information  which  may  be  desirable.  These  pencil  marks  will 
remain  after  development,  and  may  be  read  without  much  diffi- 


MARKING   THE    NEGATIVES. 


149 


eulty.  However,  it  is  not  convenient  to  prepare  each  plate  in  the 
dark  room  just  before  its  exposure,  and  it  will  be  easier  to 
mark  the  plates  in  some  way  which  does  not  require  opening 
the  envelope  or  plate-holder.  This  can  be  done  by  placing  over 
the  plate,  while  the  exposure  is  being  made,  letters  or  figures 
made  of  metal.  Small  lead  letters  and  figures  such  as  are 
used  by  pattern-makers  and  are  sold  as  "pattern  letters"  are 
very  convenient  for  this  purpose.  An  arrangement  which  I 
have  devised  for  supporting  these  letters  and  figures  is  shown 


Fig.  72. — Device  for  numbering  racliographic  negatives. 

in  figure  72.  In  this  device  three  sets  of  figures  from  0  to  9 
are  fastened  to  little  strips  of  celluloid,  and  arranged  so  that 
any  number  from  0  to  999  may  be  selected  and  placed  over 
the  plate.  These  numbers  are  fastened  to  the  under  surface 
of  the  celluloid  by  little  strips  of  surgeon's  plaster.  It  will  be 
noticed  that  they  are  arranged  so  that  in  the  negative  when 
it  is  viewed  from  the  back,  and  also  in  the  print,  the  letters 
will  read  from  left  to  right.  The  appearance  of  a  print  from 


150  RADIOGRAPHY. 

a  negative  marked  in  this  way  is  shown  in  figure  73.  In  addition 
to  the  operator's  initials,  it  will  often  be  convenient  to  mark 
the  negative  with  the'letters  R.,  L.,  A.,  P.,  I.,  or  E.,  indicating 
the  right  or  left  side  of  the  body,  and  whether  anterior  or 
posterior,  internal  or  external,  side  of  the  subject  is  placed 
nearest  the  plate.  In  many  cases  the  position  will  be  such 
that  these  letters  will  be  unnecessary,  but  they  are  often  found 
convenient. 

I  find  it  convenient  to  number  the  negatives  consecutively 
regardless  of  size,  and  to  record  them  in  numerical  order  in 
a  book,  adding  after  each  number  in  the  book  the  letter  A, 
B,  C,  D,  to  denote  the  size  of  the  plate.  Plates  of  the  same 
size  will  naturally  be  filed  together,  and  this  letter  enables 
one  to  tell  in  what  part  of  the  filing  case  the  plate  will  be  kept. 
It  will  not  be  necessary  to  use  more  than  three  to  five  sizes 
of  plates  at  the  very  most,  hence  filing  of  plates  of  the  same 
size  together  will  not  complicate  the  system  much. 

Record  Book. — A  sample  page  of  the  record  book  used  at 
the  Edward  N.  Gibbs  X-T&y  Laboratory  is  shown  in  figure  75. 
This  book  was  arranged  to  enable  a  fairly  detailed  record  to 
be  kept  with  as  little  writing  as  possible.  It  will  be  noticed 
that  there  are  different  columns  for  different  parts  of  the  body, 
and  the  letters  in  the  columns  indicate  whether  the  right  or 
left  side  is  shown,  whether  anterior  or  posterior,  internal  or 
external,  side  was  placed  nearest  the  plate  in  making  the  radio- 
graph. This  arrangement  in  columns  not  only  saves  writing  the 
name  of  the  part  exposed,  but  enables  one  to  readily  select 
from  the  book  the  numbers  of  all  negatives  of  any  particular 
part  of  the  body.  In  the  record  of  the  x-ray  exposures  the 
vacuum  of  the  tube  is  registered  by  the  length  of  the  spark 
gap,  the  distance  from  the  target  to  the  plate  is  registered 
in  inches,  and  the  time  of  exposure  in  seconds  or  minutes. 
This  record  book  enables  one  to  ascertain  most  of  the  data 
about  any  plate  when  its  number  is  known,  but  does  not  enable 
one  readily  to  find  a  given  negative  when  only  the  name  of 
the  patient  is  known.  Therefore  it  is  supplemented  by  a  card- 
index  in  which  the  numbers  of  the  plates  of  each  patient  are 
registered  on  a  card.  These  cards  are,  of  course,  filed  alpha- 


151 


RECORD    BOOK. 


153 


helically  according  to  the  patient's  name.  The  size  of  these 
cards  will  depend  upon  how  much  of  the  history  it  may  be 
desired  to  record.  The  patients  at  the  Edward  N.  Gibbs  X-ray 
Laboratory  are  all  cases  whose  histories  have  been  recorded  in 


r 


0 


rs 


~*»* 

£ 


the  college  dispensary  or  hospital  records.  Hence  it  is  only 
necessary  here  to  refer  to  the  hospital  or  dispensary  number 
to  enable  the  clinical  data  to  be  traced.  A  sample  of  this 
card  is  shown  in  figure  74. 


THE  EDWARD  N.  GIBBS  X-RAY   LABORATORY 


Case 
Number 


Date 


Name  of  Patient 


3290 
D 


1-3.9 


/) 
if 

ff 


J!+ 


3Z3Z 
B 


1-19 


3Z53 
J> 


3Z14 


3-3 


3z^s- 
A 


P. 


r. 


3297 
B 


3299 


Fig.  75. — Page  from  record  book  of  the 


154 


UNIVERSITY  AND  BELLEVUE  HOSPITAL  MEDICAL  COU.EOB 


*i 


AT 


If  203. 


/2/s 


/M 


/fc 


/r 


Edward  X.  Gibbs  X-ray  Laboratory. 


155 


156 


RADIOGRAPHY. 


Preserving  the  Negatives. — It  is  well  to  protect  the  nega- 
tives in  ordinary  manila  paper  envelopes  which  are  made  for 
that  purpose  and  sold  as  "negative  preservers"  at  all  photo- 
graphic supply  houses.  Negatives  may  then  be  filed  in  cases 
such  as  are  shown  in  figure  76.  As  will  be  seen,  these  cases 
are  divided  by  vertical  partitions  into  compartments  about 
two  inches  wide  which  will  hold  conveniently  about  a  dozen 
negatives.  The  envelopes  are,  of  course,  numbered  in  the 


Fig.  76. — Filing  case  for  negatives,  showing  indicators  for  radiographs  of  differ- 
ent parts  of  the  body. 

corner  to  facilitate  finding  any  plate,  and  these  numbers  are 
also  marked  on  a  card  at  the  base  of  the  compartment. 

A  large  collection  of  negatives  which  are  so  carefully  filed 
and  indexed  that  radiographs  of  any  particular  part  of  the 
body  may  be  readily  selected  from  the  case  for  comparison 
will  often  prove  very  valuable  and  aid  in  the  correct  inter- 
pretation of  other  radiographs,  and  in  determining  what  sort 


RADIOGRAPHS    OF   THE    UPPER    EXTREMITY.  157 

of  an  exposure  may  be  best  for  obtaining  a  given  result.  To 
assist  in  selecting  from  the  filing  case  negatives  showing 
any  part  of  the  body  I  have  devised  a  marking  system  for 
the  envelopes  which  is  visible  from  the  edge,  and  which  indicates 
at  a  glance  whether  the  negative  contained  in  it  shows  a  head, 
shoulder,  foot,  arm,  etc.  The  front  edge  of  each  envelope  is 
divided  by  two  horizontal  lines  into  three  equal  spaces,  each 
one-third  of  the  length  of  the  envelope.  The  envelopes  are 
prepared  with  these  horizontal  lines.  The  indicator  consists  of 
a  little  piece  of  gummed  colored  paper  which  may  be  pasted 
on  the  edge  of  the  envelope,  and  which  by  its  position  indicates 
the  part  of  the  body  shown  in  the  negative.  If  the  negative 
shows  the  head,  neck,  thorax,  abdomen,  or  pelvis,  the  paster 
is  placed  in  the  upper  one  of  the  three  spaces,  and  its  position 
from  top  to  bottom  of  the  space  indicates  which  of  these  five 
parts  are  shown.  In  a  like  manner  the  five  divisions  of  the 
upper  extremity — that  is,  shoulder,  humerus,  elbow,  forearm, 
wrist  and  hand — are  indicated  by  the  position  of  the  paster 
in  the  middle  space.  In  the  same  way  the  divisions  of  the 
lower  extremities — that  is,  hip-joint,  thigh,  knee,  leg,  ankle  and 
foot — are  shown  by  the  different  positions  of  the  paster  in  the 
lo\ver  division  of  the  envelope.  Obviously  an  envelope  with  the 
paster  at  the  bottom  of  the  lower  division  contains  a  negative 
of  the  foot.  A  radiograph  of  the  head  will  be  marked  by  the 
paster  at  the  top  of  the  upper  division,  a  radiograph  of  the 
elbow  will  be  marked  by  a  paster  at  the  middle  of  the  middle 
division,  etc.  This  filing  system  is,  of  course,  more  elaborate 
than  will  ordinarily  be  needed.  However,  there  are  men  who 
have  cases  under  observation  for  years,  and  often  find  it  advis- 
able to  refer  to  radiographs  made  a  long  time  previously,  and 
for  these  the  value  of  such  a  system  will  be  apparent. 

Upper  Extremity. — Radiographs  of  the  upper  extremity  will 
naturally  fall  into  the  five  divisions  mentioned  above;  that  is, 
shoulder,  arm,  elbow,  forearm,  wrist  and  hand.  All  of  these 
parts  in  the  normal  subject  are  comparatively  easy  to  radio- 
graph; and  in  cases  of  injury  to  these  parts  the  only  difficulty 
is  that  of  securing  proper  relation  of  plate,  tube,  and  subject 
without  discomfort  to  the  patient. 


158  RADIOGRAPHY. 

The  wrist  and  hand  are  perhaps  the  easiest  parts  of  the 
body  to  radiograph.  There  are  ordinarily  two  positions  in  which 
these  parts  are  shown — that  is,  from  front  to  back  and  from 
side  to  side. 

For  the  antero-posterior  view  by  far  the  most  convenient 
arrangement  will  be  to  rest  the  hand  with  the  palmar  surface 
upon  the  plate,  and  place  the  tube  over  it  at  a  distance  of  12 
to  18  inches ;  the  only  special  precaution  necessary  is  to  have 
the  forearm  well  supported  so  that  no  movement  occurs  during 
exposure.  Any  table  will  answer  perfectly  well  for  this,  but 
it  is  convenient  to  have  it  adjustable  to  suit  the  height  of  the 
patient.  The  tube-holder  shown  in  figure  63  with  the  adjustable 
shelf  is  very  convenient  for  this  purpose. 

For  a  side  to  side  view  of  the  wrist  and  hand  it  is  only  neces- 
sary to  rotate  the  hand  through  an  arc  of  90  degrees,  and  this 
will  be  readily  accomplished  by  supination  of  the  forearm.  The 
method  of  radiographing  the  middle  of  the  forearm  does  not 
differ  essentially  from  that  for  the  wrist. 

Elbow. — For  radiographing  the  upper  part  of  the  forearm,  the 
elbow-joint,  and  lower  part  of  the  humerus  the  same  tube- 
holder  and  shelf  will  be  found  of  the  greatest  convenience. 
It  will  be  usually  desirable  to  make  two  radiographs  of  this 
part — antero-posterior  and  lateral. 

Injuries  of  the  elbow-joint  are  often  accompanied  by  anchy- 
losis and  some  deformity  which  makes  it  difficult  to  secure 
proper  relations  of  the  tube,  arm,  and  plate,  and  it  therefore 
becomes  almost  a  necessity  to  use  some  special  form  of  sup- 
porting device,  such  as  the  ones  shown  in  figures  63  and  64. 

In  making  an  antero-posterior  view  of  the  elbow  it  is  always 
a  great  advantage  to  have  the  plate  in  a  plane  parallel  with 
that  through  the  condyles  of  the  humerus.  The  prominent  inner 
condyle  can  always  be  felt,  and  if  on  account  of  swelling  the 
external  epicondyle  cannot  be  felt,  the  position  can  be  estimated 
with  considerable  accuracy  by  remembering  its  relation  with  the 
olecranon,  which  is  always  palpable. 

Very  often  there  will  be  flexion  with  anchylosis  and  inability 
to  turn  the  humerus  so  that  the  condyles  are  in  a  horizontal 
plane  without  great  discomfort.  In  such  a  case  the  shelf  on 


RADIOGRAPHS   OF   THE    ELBOW. 


159 


the  radiographic  stand  may  be  tilted  by  means  of  the  ball- 
bearing clamp  until  the  plane  of  the  plate  is  in  a  plane  parallel 
with  that  through  the  condyles  of  the  humerus. 


Fig.  77. — Tube-holder  with  shelf  and  hand-rest  arranged  for  making  an 
antero-posterior  view  of  condyles  of  humerus  when  elbow  is  anchylosed  in  a 
flexed  position. 

In  case  the  limb  is  anchylosed  in  a  flexed  position  it  will 
be  necessary  to  support  the  wrist  and  hand  in  some  way,  and 
keep  it  steady  during  the  exposure.  This  may  be  accomplished 


160  RADIOGRAPHY. 

by  an  adjustable  support,  which  may  be  fastened  to  the  shelf 
as  shown  in  figure  77. 

Arm. — Radiographs  of  the  middle  third  of  the  humerus  can 
be  most  easily  made  with  the  patient  lying  on  a  table. 

For  an  antero-posterior  view  the  plate  will  naturally  be  placed 
under  the  back  of  the  arm  and  will  probably  need  to  be  propped 
up  by  blocks  to  bring  it  into  close  contact  with  the  part. 

For  a  lateral  view  it  will  be  usually  found  most  convenient 
to  slip  the  plate  between  the  arm  and  the  side  of  the  thorax, 
and  direct  the  rays  toward  it  in  nearly  a  horizontal  direction. 

If  two  views  are  made  from  different  directions  it  is  well 
to  remember  that  the  humerus  is  capable  of  rotation  at  the 
shoulder-joint,  and  to  be  sure  that  the  change  in  position  of 
plate  and  tube  is  not  compensated  for  by  such  a  rotation.  In 
case  of  injury  to  the  arm  and  shoulder  the  bandages  and  splints 
which  are  used  will  very  often  make  it  difficult  to  properly 
place  the  plate,  and  much  ingenuity  may  be  required  in  order 
to  obtain  a  satisfactory  shadow  without  removing  the  dressings. 

Shoulder-joint. — Owing  to  the  position  of  the  shoulder-joint 
at  the  side  of  the  thorax,  it  is  obviously  impossible  to  obtain 
a  radiograph  in  the  lateral  direction. 

There  are  two  methods  of  making  antero-posterior  views. 
The  easiest  one  is  to  allow  the  patient  to  lie  on  his  back  with 
the  plate  under  the  joint,  but  in  some  cases  this  cannot  be 
done  without  great  discomfort.  There  are  also  cases  in  which 
the  shoulder-joint  is  placed  so  far  forward  that  it  cannot  be 
brought  near  the  table  in  this  position.  For  such  a  case  the 
plate  may  be  placed  at  the  front  of  the  joint  and  the  tube 
behind.  This  may  be  done  by  having  him  lie  face  downward 
upon  the  plate,  but  it  can  be  better  accomplished  by  having 
him  sit  in  a  chair  or  stool  and  lean  forward  against  a  firm  ver- 
tical support  for  the  plate  (as  shown  in  Fig.  78).  The  move- 
ments of  respiration  may  be  communicated  to  the  shoulder- 
joint,  and  it  is  therefore  desirable  to  make  the  exposure  short 
enough  so  that  the  patient  can  conveniently  hold  his  breath 
while  the  radiograph  is  being  made. 

In  radiographs  of  the  shoulder-joint  it  will  be  desirable  to 
show  the  anatomical  neck  and  the  greater  tuberosity.  In  order 


RADIOGRAPHS    OF    THE    SHOULDER-JOINT. 


161 


to  do  this  to  the  best  advantage  the  arm  should  be  rotated 
so  as  to  bring  the  anatomical  neck  in  a  plane  approximately 
parallel  to  that  of  the  plate.  In  doing  this  it  is  convenient  to 
remember  that  the  direction  of  the  prominent  inner  condyle 
of  the  humerus  corresponds  very  nearly  with  that  of  the  ana- 
tomical neck. 

The  joint  will  be  shown  best  if  the  plate  is  at  the  back,  with 
the  target  of  the  tube  at  about 
the  level  of  the  glenoid  cavity, 
and  about  2  or  3  inches  inter- 
nal to  it,  the  distance  between 
the  tube  and  plate  being  about 
15  to  18  inches.  If  the  tube  is 
at  the  back,  the  target  should 
be  placed  about  2  or  3  inches 
external  to  the  glenoid  cavity. 

Subluxation  of  the  humerus 
will  be  shown  satisfactorily  by 
a  single  antero-posterior  view. 

In  displacements  of  the  head 
of  the  humerus  in  an  antero- 
posterior  direction  a  single  ra- 
diograph may  fail  to  show 
whether  the  head  is  displaced 
backward  or  forward.  For  such 
a  condition  it  is  useful  to  make 
stereoscopic  radiographs  accord- 
ing to  the  methods  described 
elsewhere.  Another  way  to  de- 
termine whether  the  displace- 
ment is  backward  or  forward  is 
to  make  two  radiographs,  one 

with  the  tube  in  the  position  described  above,  and  another 
with  the  tube  moved  outward  about  6  or  8  inches  from  this 
position.  If  the  displacement  is  forward,  there  will  be  in  the 
first  radiograph  less  overlapping  of  the  shadows  of  the  head  of 
the  humerus  and  the  glenoid  fossa  than  in  the  second.  If  the 
displacement  is  backward,  the  reverse  will  be  true. 
11 


Fig.  78. — Dr.  Cowl's  plate  sup- 
port for  radiographing  thorax  and 
shoulder. 


162  RADIOGRAPHY. 

Scapula. — The  acromion  process  will  be  usually  shown  very 
clearly  in  radiographs  of  the  shoulder-joint  made  in  the  manner 
described  above. 

Fractures  of  the  body  of  the  scapula  occur  very  rarely  and 
will  be  easily  shown  by  any  antero-posterior  view. 

In  order  to  show  the  body  of  the  scapula  to  the  best  advantage 
it  will  of  course  be  well  to  place  the  plate  at  the  back,  and 
to  adjust  it  as  nearly  as  possible  in  a  plane  parallel  to  that 
of  the  flat  portion  of  the  bone. 

The  coracoid  process  shows  in  the  ordinary  radiograph  of 
the  shoulder  superimposed  upon  the  shadow  of  the  spine  of 
the  scapula,  and  therefore  in  order  to  obtain  a  radiograph  of  a 
fracture  of  this  part  of  the  bone  it  is  better  to  place  the  source 
of  the  x-ray  in  front,  and  at  a  level  considerably  below  the 
shoulder-joint,  so  as  to  throw  the  shadow  of  the  coracoid  upward 
and  backward.  With  the  patient  lying  on  his  back  the  plate 
can  then  be.  placed  vertically  and  at  the  top  of  the  shoulder. 
The  arm  should  be  abducted  as  much  as  possible  and  the  tube 
should  be  placed  at  a  level  10  or  12  inches  below  the  shoulder- 
joint  very  close  to  the  thorax.  In  order  to  avoid  the  risk 
of  burning  the  part  of  the  body  which  is  nearest  the  tube  a 
sheet  of  lead  may  be  laid  over  the  lower  part  of  the  thorax. 
If  this  sheet-lead  is  connected  to  a  ground  wire,  the  tube  may 
be  brought  very  close  indeed  without  danger  of  burning  or 
shock  to  the  patient.  Radiographs  made  in  this  way  will  show 
very  little  except  the  clavicle  and  the  coracoid  process.  (See 
Fig.  79.) 

Clavicle. — The  clavicle  can  be  best  shown  by  placing  the  plate 
in  front  and  as  close  to  the  body  as  possible  with  the  tube 
behind.  In  fractures  of  this  bone  vertical  displacements  of  the 
fragments  will  be  shown  in  a  single  radiograph. 

Antero-posterior  displacements  may  be  shown  either  by 
making  stereoscopic  exposures,  or  by  making  two  radiographs 
with  the  position  of  the  tube  changed  about  8  or  10  inches 
horizontally  or  vertically.  If  there  is  no  antero-posterior  dis- 
placement, the  distance  between  the  shadows  of  the  ends  of 
the  fragments  will  be  about  the  same  in  both  radiographs. 
The  end  of  the  fragment  whose  shadow  changes  the  most  in 


Fig.  79. — Radiograph  by  E.  \V.  Calilwell  showing  coracoid  process.  Hammer 
Aurora  plate,  glycin  developer.  Water-cooled  tube,  target  18  inches  from  plate.  Ex- 
posure six  seconds  (no  intensifying  screen). 


163 


RADIOGRAPHS   OF   THE    FOOT.  165 

position  in  the  two  radiographs  will  be  further  from  the  plate 
than  the  other. 

It  is  well  to  remember  that  at  the  acromio-clavicular  articula- 
tion there  is  a  cartilage  which  casts  no  shadow,  and  the  radio- 
graph shows,  therefore,  normally  considerable  separation  be- 
tween the  bones.  The  shadow  of  the  end  of  the  clavicle  usually 
projects  somewhat  above  the  shadow  of  the  acromion,  and  these 
appearances  of  the  radiographs  of  the  normal  part  might  be 
mistaken  for  slight  dislocation. 

For  showing  the  sterno-clavicular  articulation  the  plate  should 
be  placed  in  front,  and  the  tube  at  the  back,  a  little  to  one 
side  or  the  other  in  order  to  avoid  superimposing  the  shadow 
of  the  spine  upon  the  joint. 

Foot. — Injuries  of  the  metatarsal  bones  and  phalanges  will 
be  easily  shown  by  a  single  antero-posterior  view.  This  can  be 
made  with  the  patient  sitting  in  a  chair  with  the  sole  of  the 
foot  resting  upon  the  plate,  which  may  be  upon  the  floor,  or 
supported  upon  a  low  stool  or  a  block  of  wood. 

In  making  a  lateral  view  it  will  be  well  to  place  the  tube 
in  such  a  position  that  the  shadows  of  the  metatarsal  bones 
will  not  be  superimposed,  and  to  place  the  plate  at  the  side 
of  the  foot  which  is  nearest  the  injury.  The  shelf  which  is 
attached  to  the  tube-stand  shown  in  figure  63  will  be  con- 
venient for  supporting  the  foot  and  leg. 

Medio-tarsal  Joint. — In  making  an  antero-posterior  view  of 
the  medio-tarsal  joint  the  leg  may  be  drawn  inward  and  back- 
ward so  that  the  tube  can  be  placed  directly  over  the  joint 
in  the  position  shown  in  figure  80. 

Ankle. — The  antero-posterior  view  of  the  ankle  will  show  the 
lower  extremities  of  tibia  and  fibula,  and  the  surfaces  of  the 
astragalus  with  which  they  articulate,  but  it  is  practically 
impossible  to  show  the  os  calcis  in  this  position.  It  will  be 
better  to  place  the  plate  at  the  back  of  the  ankle  and  the  tube 
in  front,  directly  over  the  joint.  This  radiograph  can  be  made 
either  with  the  patient  lying  down,  or  sitting  in  a  chair  with 
the  foot  and  leg  supported  by  the  shelf  mentioned  above,  using 
the  hand-rest  to  clamp  the  ball  of  the  foot  so  that  it  does  not 
move  from  side  to  side. 


166 


RADIOGRAPHY. 


A  lateral  view  of  the  ankle  will  show  the  fibula  better  if 
the  outer  side  of  the  leg  is  placed  nearest  the  plate.  If  this 
radiograph  is  made  with  the  patient  in  a  sitting  position,  it 
will  sometimes  be  necessary  to  place  the  plate  in  a  vertical 
position  and  send  the  rays  through  in  a  horizontal  direction. 


Fig.  80. — Method  of  making  antero-posterior  view  of  foot  to  show  medio-tarsal 

joint. 

When  this  is  done,  it  will  be  convenient  to  rest  the  leg  and 
heel  upon  a  narrow  block  of  wood  hi  order  to  bring  it  well 
above  the  lower  edge  of  the  plate. 

Leg. — The   above   suggestions   for  radiographing  the   ankle 
apply  equally  well  for  the  leg. 


Fig.  81. — Radiograph  by  E.  W.  Caldwell  showing  needle  hetween  ankle-joint 

and  tendo  Achillis. 


167 


RADIOGRAPHS   OF   THE    KNEE-JOINT.  169 

In  both  the  antero-posterior  and  lateral  views  it  will  be 
better  to  place  the  tube  in  such  a  position  that  the  shadows 
of  the  two  bones  do  not  overlap. 

In  making  an  antero-posterior  view  the  tube  should  be  placed 
opposite  the  middle  line  of  the  leg.  In  the  lateral  view  the 
shadows  of  the  two  bones  will  be  separated  if  the  tube  is  placed 
so  that  the  rays  pass  a  little  diagonally  through  the  leg;  i.  e.,  a 
little  in  front  of  the  leg  if  the  plate  is  at  the  inner  side,  and 
a  little  behind  if  the  plate  is  at  the  outer  side  of  the  leg. 

Knee-joint. — Lateral  views  of  the  knee-joint  show  the  tendon 
of  the  quadriceps  extensor,  the  patellar  ligament,  the  patella, 
and  the  other  bones  of  the  joint. 

The  antero-posterior  views  usually  show  the  condyles  of  the 
femur,  the  head  of  the  fibula,  and  the  upper  extremity  of  the 
tibia.  The  patella  is  superimposed  upon  the  lower  end  of  the 
femur,  and  usually  shows  only  faintly  unless  the  plate  is  placed 
in  front  of  the  joint  with  the  tube  behind.  The  semilunar 
fibre-cartilages  cast  little  or  no  shadow,  and  displacements  of 
these  cartilages  are  not  readily  shown  in  a  radiograph.  Sesa- 
moid  bones  are  occasionally  shown  in  some  of  the  tendons 
back  of  the  joint. 

The  antero-posterior  view  can  be  made  most  conveniently 
with  the  patient  lying  on  his  back,  and  the  plate  underneath 
the  joint.  If  it  is  desired  to  show  the  patella,  or  if  the  joint 
is  anchylosed  in  a  flexed  position,  it  will  be  better  to  place 
the  plate  at  the  front  of  the  knee,  the  patient  lying  face  down- 
ward. 

Lateral  views  can  be  made  with  the  patient  lying  on  his 
side  with  the  plate  underneath  the  knee.  There  will  be  less 
danger  of  movement  if  the  leg  is  flexed  or  semiflexed.  The 
head  of  the  fibula  will  be  shown  best  when  the  plate  is  placed 
at  the  outer  side  of  the  knee.  The  articular  surfaces  should 
be  accurately  located  in  order  that  the  rays  may  be  passed 
directly  through  the  joint.  When  the  knee  is  very  much  swollen, 
this  is  not  always  easy.  The  lower  extremity  of  the  patella  is  a 
guide  to  the  joint  in  normal  subjects.  When  this  landmark 
cannot  be  made  use  of,  the  joint  can  be  located  a  little  above 
the  head  of  the  fibula,  which  is  always  palpable. 


1 70  RADIOGRAPHY. 

Thigh. — Radiographs  of  the  thigh  will  almost  invariably  be 
made  either  for  examining  fractures  of  the  femur  or  for  locating 
foreign  bodies.  The  proper  relation  with  tube  and  plate  will 
easily  be  secured  with  the  patient  in  the  recumbent  position. 

Hip-joint. — The  hip-joint  of  a  large  adult  is  a  difficult  subject 
to  radiograph  satisfactorily.  A  good  radiograph  of  this  part 
should  show  the  head  of  the  femur,  the  neck,  and  the  greater 
and  lesser  trochanters  distinctly.  Owing  to  its  position  it  is 
usually  impossible  to  show  the  acetabulum  very  well.  Radio- 
graphs of  this  joint  will  be  useful  in  diagnosis  of  fractures, 
dislocations,  and  in  diseased  conditions  of  the  bones.  In  old 
fractures  there  will  almost  always  be  an  apparent  shortening 
of  the  anatomical  neck  of  the  femur  and  the  line  of  the  fracture 
will  be  shown  more  or  less  imperfectly.  Unless  there  is  con- 
siderable deformity  it  will  usually  be  impossible  to  judge  how 
firmly  the  fragments  have  united.  For  obvious  reasons  it  will 
be  impossible  to  obtain  lateral  views  of  this  joint. 

Radiographs  of  the  hip-joint  will  usually  be  made  with  the 
most  comfort  to  the  patient  by  having  him  lie  on  his  back 
upon  the  plate  with  the  tube  above,  but  sometimes  when  there 
is  a  great  deal  of  adipose  tissue  in  the  gluteal  region  the  plate 
can  be  brought  very  much  nearer  the  joint  by  placing  it  in 
front  of  the  body,  using  a  canvas-topped  table,  or  allowing  the 
patient  to  lie  face  downward  on  the  plate.  The  tube  should 
be  18  to  24  inches  away  from  the  plate,  and  at  about  the  level 
of  the  crest  of  the  pubes.  It  may  be  placed  over  the  joint 
or  directly  over  the  median  line.  If  both  sides  of  the  body 
are  shown  for  comparison,  the  tube  will,  of  course,  be  placed 
over  the  median  line  at  the  level  of  the  pubic  crest. 

The  anatomical  neck  of  the  femur  will  be  shown  best  if  it 
is  rotated  into  a  plane  parallel  with  that  of  the  plate.  This 
will  be  done  by  turning  the  feet  inward,  strapping  them  to- 
gether, and  placing  a  block  three  or  four  inches  wide  between 
the  heels  to  keep  them  apart.  Sand-bags  should  be  placed 
over  the  knees  to  steady  the  legs.  This  position  of  almost 
complete  adduction  of  the  thighs  will  be  preferable  in  nearly 
every  case,  although  sometimes  it  may  be  desirable  or  necessary 
to  radiograph  the  joint  with  the  thigh  abducted. 


RADIOGRAPHS   OF   THE    HEAD,    FACE,    NECK.  171 

This  part  of  the  body  is  so  thick  that  it  will  be  necessary 
to  use  a  tube  of  moderately  high  penetration,  but  it  must  be 
remembered  that  tubes  of  too  great  penetration  will  not  give 
contrasty  pictures.  A  single  radiograph  showing  the  whole 
pelvis  will  usually  be  sufficient  in  cases  of  congenital  dislocations. 
Stereoscopic  pictures  of  the  joint  may  be  made,  or  the  antero- 
posterior  displacements  may  be  shown  by  two  radiographs 
made  according  to  the  methods  described  for  the  shoulder- 
joint. 

Head,  Face,  Neck. — In  this  region  we  have  to  consider  the 
skull,  bones  of  the  face,  cervical  vertebrae,  larynx,  pharynx, 
and  upper  parts  of  the  trachea  and  esophagus. 

Radiographs  of  the  skull  are  usually  made  for  locating  bullets 
in  the  head  and  pieces  of  metal  in  the  eye.  For  such  injuries 
diagnosis  with  the  z-ray  will  usually  be  satisfactory.  It  is 
sometimes  possible  to  show  in  a  radiograph  fractures  of  the 
skull,  and  occasionally  tumors  or  other  lesions  of  the  brain. 
Success  in  the  diagnosis  of  such  conditions  depends  largely  upon 
the  thickness  of  the  skull,  which  varies  greatly  in  different 
individuals.  For  determining  the  position  of  bullets  in  the 
head  and  foreign  bodies  in  the  eye  special  apparatus  and  tech- 
nique are  necessary,  and  will  be  described  under  the  subject 
of  localization  of  foreign  bodies. 

It  has  been  mentioned  before  that  exposure  to  the  x-ray 
which  is  insufficient  to  cause  burns  may  be  enough  to  cause 
loss  of  hair  from  one  side  of  the  head,  and  great  distress  to 
the  patient.  Care  must  therefore  be  exercised  to  avoid  over- 
exposure  in  this  part  of  the  body.  The  tube  should  be  about 
15  to  20  inches  from  the  plate. 

In  radiographing  the  skull  it  is  necessary  to  be  very  careful 
to  support  the  head  in  such  a  way  that  it  cannot  roll.  Espe- 
cially is  this  necessary  if  two  exposures  are  to  be  made  in  the 
same  position  for  the  location  of  a  foreign  body.  When  the 
condition  of  the  patient  will  allow,  the  sitting  posture  will 
be  convenient,  the  head  being  supported  at  the  back  by  a 
right-angled  arrangement  of  wood  which  may  be  attached  to 
the  head-rest  of  the  regular  surgeon's  chair.  Mackenzie  David- 
son has  made  a  very  convenient  arrangement  of  this  kind 


172 


RADIOGRAPHY. 


which  has  an  adjustable  rest  for  the  chin  to  aid  in  preventing 
movement  of  the  head. 

If  the  patient  is  unable  to  sit  in  a  chair,  he  may  lie  on  his 
back.  For  supporting  the  head  in  this  position  I  have  devised 
an  adjustable  sling  of  canvas  which  is  shown  in  figure  82.  This 
sling  is  adjustable  in  height  to  suit  the  comfort  of  the  subject 


Fig.  82. — Canvas  hammock  for  supporting  the  head  in  radiographic  exposures. 

and  fits  closely  against  the  head  so  as  to  prevent  rotation. 
It  is  pliable  and  makes  a  fairly  comfortable  pillow. 

For  making  antero-posterior  views  with  the  plate  at  the  back 
of  the  head  there  is  an  adjustable  shelf  for  supporting  the 
plate.  For  lateral  view  the  plate  is  rested  vertically  upon  this 
shelf,  and  the  rays  passed  through  the  head  in  a  horizontal 
direction.  A  convenient  method  of  making  antero-posterior 


RADIOGRAPHS    OF   THE    TEETH.  173 

views  with  the  plate  at  the  front  of  the  head  is  to  use  the  canvas- 
topped  table  and  place  the  tube  underneath. 

Face. — Radiographs  of  the  bones  of  the  face  are  usually 
unsatisfactory  because  the  two  sides  are  superimposed  upon 
each  other  in  the  picture.  The  position  which  has  just  been 
mentioned  for  radiographing  the  skull  will  be  equally  conve- 
nient for  the  face. 

Teeth. — Radiographs  may  be  used  satisfactorily  for  showing 
teeth  which  have  not  erupted,  diseased  conditions  of  the  alveolar 
process,  and  foreign  bodies  such  as  pieces  of  drills,  etc. 

Radiographs  showing  the  teeth  may  be  made  on  glass  plates 
in  this  position,  and  by  properly  placing  the  tube  the  shadows 
of  the  two  sides  of  the  jaws  may  be  kept  from  overlapping. 
This  will  be  easier  if  the  mouth  is  kept'open  by  a  cork  or  piece 
of  wood  placed  between  the  teeth.  The  tube  may  then  be 
readily  placed  in  such  a  position  that  one  row  of  teeth  will 
be  shown  without  any  other  parts  being  superimposed  upon 
it.  The  side  to  be  radiographed  will,  of  course,  be  placed 
nearest  the  plate. 

A  better  way  of  radiographing  the  teeth,  however,  is  to 
place  within  the  mouth  a  small  piece  of  photographic  film 
enclosed  in  a  water-tight  envelope.  The  best  film  to  use  is 
the  regular  double-coated  cut  film,  although  the  ordinary  roll 
film  used  in  hand  cameras  can  also  be  used.  The  roll  films 
are  thin  enough  so  that  several  layers  may  be  used  in  the 
envelope,  thus  obtaining  several  negatives  by  the  same  expos- 
ure. For  protecting  the  film  against  light  and  moisture  one 
of  the  best  materials  is  soft  black  dental  rubber,  which  may 
be  obtained  from  any  dental  supply  house.  This  substance  is 
opaque  to  light  and  fairly  transparent  to  the  ray.  The  thin 
sheets  are  soft  and  sticky,  and  readily  sealed  by  pinching  the 
freshly  cut  edges  with  a  pair  of  pliers.  The  film  may  be  placed 
between  two  sheets  of  tissue  paper  to  prevent  it  from  sticking 
to  the  rubber  and  then  placed  between  two  sheets  of  dental 
rubber.  The  sandwich  thus  formed  may  be  cut  to  any  desired 
size  and  shape  with  scissors,  and  the  edges  of  the  rubber  pinched 
together,  forming  an  envelope  which  is  very  little  larger  than 
the  film  it  contains.  The  patient  may  hold  the  film  with  his 


174  RADIOGRAPHY. 

finger  in  the  mouth  behind  the  teeth  which  it  is  desired  to 
radiograph.  With  this  arrangement  the  exposure  will  be  some- 
what less  than  when  the  radiograph  is  made  through  the  side 
of  the  face,  and  it  should  not  exceed  a  few  seconds. 

Neck. — The  upper  three  or  four  cervical  vertebra?  cannot  be 
shown  in  the  antero-posterior  direction,  because  the  shadow 
of  the  lower  jaw  will  be  superimposed  upon  them.  In  the 
lateral  direction  it  is  usually  feasible  to  show  the  upper  six 
cervical  vertebra?.  It  is  usually  difficult  to  press  the  plate  far 
enough  down  upon  the  shoulder  to  show  the  seventh. 

Displacements  of  these  vertebrae  may  be  shown  by  stereo- 
scopic methods,  or  by  making  two  radiographs  from  different 
positions  in  the  manner  which  has  been  described  for  other 
joints.  In  a  good  lateral  view  of  the  neck  the  cartilages  of 
the  larynx  will  show  faintly,  and  the  trachea  will  appear  as 
a  darker  streak  on  the  negative.  The  hyoid  bone  will  be  shown 
plainly,  and  there  will  be  no  difficulty  in  showing  metallic 
bodies,  such  as  pins  and  buttons,  in  this  region.  For  radio- 
graphing the  neck  it  will  be  convenient  to  use  the  support 
for  the  head  which  has  been  described  before. 

In  order  to  show  the  lower  cervical  vertebrae  it  will  some- 
times be  of  advantage  to  place  a  bandage  around  the  shoulder 
so  as  to  press  down  the  muscles  running  between  the  neck 
and  scapula,  and  thus  allow  the  plate  to  be  placed  in  a  slightly 
lower  position. 

Thorax. — Radiographs  of  the  thorax  give  useful  information 
of  many  abnormal  conditions  of  the  organs  in  this  region. 
Areas  of  consolidation  and  cavities  in  the  lungs  due  to  tuber- 
culosis will  be  readily  shown;  abnormal  changes  in  the  size, 
shape,  and  position  of  the  heart  and  great  vessels  can  often 
be  demonstrated.  Liquids  in  the  pleural  sac  offer  considerable 
obstruction  to  the  x-rays  and  cast  dense  shadows. 

The  cartilages  of  the  bronchi  vary  considerably  in  thickness 
in  different  individuals,  and  the  shadows  they  cast  in  the  radio- 
graph have  sometimes  been  mistaken  for  areas  of  consolida- 
tion in  the  lungs. 

The  interpretation  of  radiographs  of  this  part  of  the  body 
requires  a  great  deal  of  experience  and  an  intimate  knowledge 


POSITION   OF   THE    PATIENT.  175 

of  the  pathology  of  these  organs.  This  phase  of  the  subject 
has  been  ably  elucidated  in  the  works  of  Holzknecht,  BeClere, 
Williams,  and  others.  Owing  to  the  fact  that  the  lungs  offer 
very  little  obstruction  to  the  x-rays,  radiographs  of  the  thorax 
may  be  made  with  much  shorter  exposures  than  are  necessary 
for  the  abdomen  and  pelvis.  On  account  of  the  movements  of 
respiration,  it  is  very  desirable  that  exposures  in  this  region 
should  be  very  short:  if  possible,  within  the  length  of  time 
that  a  patient  may  hold  his  breath  comfortably.  Radiographs 
of  the  thorax  have  been  made  with  exposures  of  about  one 
second  by  Von  Ziemssen  and  Rieder,  who  use  the  method 
published  by  Rosenthal  in  the  Miincher  medicinische  Wochen- 
schrift,  1899,  No.  32,  and  which  is  described  as  follows: 

"Rosenthal  employs  a  Volt -Ohm  apparatus  with  a  60- 
centimeter  coil,  and  electrolytic  interrupter  and  Volt-Ohm 
tube.  The  time  of  exposure  is  essentially  shortened  by  the 
use  of  two  intensifying  screens,  the  one  being  placed  with  its 
coated  side  against  the  coated  side  of  the  film,  and  the  Schleuss- 
ner  film  laid  between  the  intensifying  screens,  the  coated  sides 
of  which  are  toward  the  photographic  plate.  These  are  then 
enclosed  in  three  light-tight  envelopes.  The  patient  lies  on 
his  belly  or  back  upon  the  photographic  plate,  or  the  plate 
is  placed  upon  the  particular  part  desired  to  photograph  and 
the  current  is  opened  for  a  moment  and  as  quickly  closed. 
The  plates  are  then  removed  and  developed  in  the  usual  manner." 

Films  coated  on  both  sides  require  considerable  pains  in  the 
development,  and  the  intensifying  screens  also  cause  a  certain 
amount  of  blurring  or  mottling  which  is  especially  noticeable  if 
the  exposure  is  a  little  too  long.  In  ordinary  practice,  therefore, 
it  would  seem  just  as  well  to  expose  ten  to  twenty  seconds 
(with  the  patient  holding  his  breath),  and  use  the  regular  double 
coated  plates  without  any  intensifying  screens.  Sharper  pictures 
will  be  obtained,  and  the  photographic  manipulations  will  be 
simplified. 

Position  of  the  Patient. — Gravity  has  considerable  effect  upon 
the  position  of  the  thoracic  viscera,  and  for  this  reason  it  is 
better  to  make  the  radiograph  with  the  patient  in  the  upright 
posture.  One  of  the  best  arrangements  is  to  let  the  patient 


176  RADIOGRAPHY. 

sit  in  a  chair  with  the  plate  in  a  holder  clamped  between  him 
and  the  back  of  the  chair,  placing  the  tube  in  front.  Some- 
times it  will  be  desirable  to  make  a  radiograph  with  the  plate 
in  contact  with  the  anterior  wall.  For  such  cases  the  patient 
may  sit  on  a  stool  and  lean  against  a  vertical  support  for  the 
plate.  Dr.  Cowl  has  devised  a  very  good  apparatus  for  sup- 
porting the  plate  in  radiographic  exposures  of  the  thorax  and 
shoulders.  This  arrangement  is  shown  in  figure  78. 

Esophagus. — The  x-ray  is  seldom,  if  ever,  of  any  value  in 
the  diagnosis  of  abnormal  conditions  of  the  esophagus.  The 
walls  of  this  canal  offer  so  little  resistance  to  the  x-rays  that 
they  cast  no  shadow.  In  order  to  show  it,  therefore,  it  has 
been  suggested  to  introduce  a  rubber  tube  filled  with  mercury 
or  shot,  or  to  introduce  bismuth  subnitrate. 

Spinal  Column. — The  usefulness  of  radiographs  of  the  spinal 
column  will  depend  very  much  upon  the  size  and  thickness 
of  the  subject.  Usually  they  will  be  satisfactory  for  showing 
lateral  curvatures  and  displacements,  and  in  favorable  cases 
they  may  show  diseased  conditions  of  the  bones. 

Radiographs  of  the  dorsal  vertebrae  are  usually  more  or  less 
'pdistinct  because  of  the  shadows  cast  by  the  sternum,  the 
liver,  and  the  viscera  of  the  mediastinum.  All  of  these  organs 
are  rather  opaque  to  the  x-rays,  and,  except  in  favorable  cases, 
it  is  impossible  to  show  these  parts  of  the  spine  with  as  much 
clearness  as  may  be  obtained  in  the  lumbar  region.  The  exposure 
should  be  long,  and  the  development  carried  to  a  point  which 
blots  out  the  other  structures  of  the  thorax.  The  plate  will,  of 
course,  be  placed  at  the  back  of  the  patient  and  the  tube  in  front. 
The  density  of  the  shadows  of  the  superimposed  tissues  will 
be  reduced  by  placing  the  tube  as  close  to  the  front  of  the 
body  as  safety  will  permit,  say  at  a  distance  of  6  to  8  inches 
from  the  skin.  The  patient  may  be  placed  either  in  a  sitting 
posture,  or  he  may  lie  on  the  plate;  or  in  case  the  back  is  so 
tender  that  it  is  not  comfortable  to  lie  on  the  hard  plate,  he 
may  lie  face  down  upon  a  canvas  stretcher  and  the  plate  may 
rest  by  gravity  over  the  back,  the  tube  being  placed  under- 
neath. 

Lumbar  Vertebrae. — For  radiographing  the  lumbar  vertebra 


RADIOGRAPHS   OF   THE    ABDOiMEN    AND    PELVIS.  177 

the  plate  will,  of  course,  be  placed  at  the  back,  and  the  tube 
in  front  and  as  near  the  abdomen  as  safety  will  permit.  The 
plate  should  be  developed  to  the  point  which  blots  out  most 
of  the  other  structures  in  this  region.  The  penetration  of  the 
tube  will  have  to  be  adjusted  to  suit  the  subject.  A  fair  pene- 
tration will  be  necessary,  but  it  is  well  to  use  as  low  a  pene- 
tration as  the  thickness  of  the  subject  will  permit. 

Abdomen  and  Pelvis. — In  the  region  below  the  diaphragm, 
radiographs  may  be  satisfactorily  used  for  showing  the  lumbar 
vertebrae,  for  detecting  stones  in  the  kidneys,  ureters,  or  bladder, 
and  for  the  location  of  bullets  or  other  foreign  bodies.  In  a 
few  cases  they  may  show  gall-stones,  enlargements  of  the  liver 
and  spleen,  or  may  be  used  for  obtaining  measurements  of  th3 
diameters  of  the  pelvis,  etc. 

The  stomach  and  intestines  offer  so  little  obstruction  to  the 
x-ray  that  ordinarily  they  do  not  produce  any  distinct  shadows 
upon  the  plate.  In  order  to  show  their  outlines  two  or  three 
methods  have  been  suggested.  One  of  these  is  to  place  in 
the  organs  some  inert  substance,  such  as  bismuth  subnitrate, 
which  will  cast  a  shadow.  Another  is  to  empty  the  canal  of 
its  contents,  and  inflate  it  with  air,  in  which  case  the  hollow 
spaces  will  show  as  dark  spots  on  the  negative.  In  case  of 
the  stomach  perhaps  the  best  way  is  to  distend  the  organ 
with  air,  and  insufflate  with  bismuth  subnitrate  by  means  of 
an  apparatus  employed  by  stomach  specialists. 

Usually  it  will  be  found  that  the  antero-posterior  view  is 
the  only  one  that  can  be  made  with  satisfaction  in  this  region. 
The  patient  may  either  lie  on  the  plate,  or  upon  a  stretcher 
with  the  plate  supported  above  him  according  to  Shenton's 
method,  or  the  plate  may  be  placed  underneath  the  stretcher 
as  advised  by  Dr.  Williams.  Exposures  for  this  part  of  the 
body  will  be  among  the  longest  that  have  to  be  made. 

Radiographs  of  the  pelvic  region  will  be  usually  made  with 
the  most  comfort  by  having  the  patient  lie  with  his  buttocks 
upon  the  plate  and  placing  the  tube  above.  The  exact  position 
of  the  tube  will  be  determined  according  to  just  what  it  is 
desired  to  show.  For  stones  in  the  lower  part  of  the  ureters 
a  position  should  be  chosen  which  will  throw  the  shadow  of 
12 


178  RADIOGRAPHY. 

the  stone  between  the  shadows  of  the  sacrum  and  the  os  in- 
nominatum.  It  may  sometimes  be  impossible  to  show  a  stone 
in  the  portion  of  the  ureter  which  lies  opposite  the  ilio-sacral 
synchrondrosis,  because  its  shadow  may  be  obscured  by  the 
shadow  of  the  pelvic  bones. 

A  number  of  methods  have  been  devised  for  obtaining  from 
radiographic  shadows  the  true  dimensions  of  the  pelvic  outlet, 
but  they  are  all  more  or  less  complicated  and  uncertain.  Per- 
haps the  best  way  is  to  determine  the  true  position  in  space 
of  the  different  points  of  the  boundaries  by  methods  which 
are  used  for  location  of  foreign  bodies,  and  determine  the 
diameters  by  graphical  methods. 

Stones  in  the  Bladder. — For  stones  in  the  bladder  the  best 
position  is  to  place  the  patient  lying  face  downward  with  the 
plate  underneath  the  pelvis.  Every  means  should  be  taken  to 
cause  the  stone  to  occupy  such  a  position  that  its  shadow 
will  fall  above  the  shadows  of  the  pubes.  The  table  should 
be  tilted  so  that  gravitation  will  carry  the  stone  forward  and 
upward.  The  thighs  should  be  somewhat  abducted  and  the  tube 
placed  at  a  level  well  below  the  folds  of  the  nates  so  that  the 
rays  will  pass  upward  and  forward  through  the  true  pelvis 
in  a  direction  nearly  parallel  with  that  of  the  upper  part  of  the 
sacrum.  This  will  usually  throw  the  shadow  of  the  stone  well 
above  that  of  the  symphysis  pubis. 

Stones  in  the  Kidneys  and  Upper  Part  of  Ureters. — It  cannot 
be  said  that  diagnosis  of  renal  calculi  by  means  of  the  x-ray 
is  in  all  cases  satisfactory.  The  difficulty  of  obtaining  radio- 
graphs of  kidney  stones  will  depend  upon  the  size  and  compo- 
sition of  the  stone,  and  perhaps  more  upon  the  size  of  the 
subject. 

Pure  uric  acid  stones  offer  very  little  obstruction  to  the  rays, 
and  cast  very  faint  shadows.  It  is  possible  that  no  radiograph 
will  absolutely  exclude  the  possibility  of  a  uric  acid  stone. 
Fortunately,  however,  there  is  almost  always  present  in  these 
stones  a  sufficient  quantity  of  oxalate  or  phosphate  of  calcium 
to  cast  fairly  good  shadows. 

A  good  radiographic  shadow  of  a  stone  may  be  taken  as 
conclusive  evidence  of  its  existence,  but  except  in  favorable 


STONES    IN    THE    KIDNEYS    AND    URETERS.  179 

subjects  if  the  radiograph  fails  to  show  a  stone  its  absence 
cannot  be  established  with  certainty.  In  general  if  the  radio- 
graph shows  well  the  shadow  of  the  twelfth  rib,  and  transverse 
processes  of  the  lumbar  vertebrae,  it  is  good  enough  to  show 
a  stone,  and  if  in  two  or  three  such  radiographs  no  stone  is 
shown  it  may  be  taken  as  very  probable  that  none  is  present. 

The  plate  should  be  invariably  placed  at  the  back  of  the 
patient,  and  at  least  one  plate  should  be  made  which  covers 
both  kidnejrs  and  which  extends  down  far  enough  to  take  in 
the  portion  of  the  ureters  above  the  ilium.  It  sometimes 
happens  that  stones  are  found  on  the  side  opposite  to  that 
in  which  the  pain  is  felt. 

In  radiographing  stones  in  the  kidneys  it  is  always  advisable 
to  use  two  plates,  placing  one  on  top  of  the  other.  It  will 
frequently  happen  that  the  lower  plate  will  be  better  than 
the  one  nearest  the  body,  but  the  real  reason  for  employing 
two  plates  is  that  with  a  single  negative  a  spot  may  appear 
which  might  be  due  to  a  stone  in  the  kidney,  or  to  an  accident 
in  development.  If  the  spot  appears  in  the  same  position  on 
two  superimposed  plates,  the  question  is  cleared  up. 

The  tube  should  be  placed  directly  in  front,  and  may  be 
in  the  median  line;  or  if  only  one  kidney  is  to  be  shown,  a 
little  to  the  right  or  left,  at  the  level  of  the  pelvis  of  the  ureter. 
The  movements  of  respiration  cause  more  or  less  disturbance 
of  this  region;  it  is  therefore  desirable  that  the  patient  hold 
his  breath  during  the  exposure,  which,  under  the  best  condi- 
tions, should  not  exceed  one  minute  in  duration. 

Shenton  prefers  to  place  the  patient  face  down  upon  a  stretcher 
and  rest  the  plate  upon  the  back.  This  method  has  the  advan- 
tage that  a  fluorescent  screen  may  be  placed  over  the  plate  and 
thus  give  a  constant  indication  as  to  the  character  of  the  rays 
delivered  by  the  tube. 

If  long  exposures  are  made,  Shenton 's  position  has  the  ad- 
vantage that  it  compresses  the  abdominal  viscera,  reducing 
somewhat  the  movements  of  respiration.  A  somewhat  easier 
method  is  to  allow  the  patient  to  lie  on  his  back  with  the  plate 
underneath,  and  place  the  tube  above.  This  position  allows 
the  operator  to  watch  the  target  of  the  tube  to  see  that  it  does 


180  RADIOGRAPHY. 

not  become  overheated.  It  is  obvious  that  the  water-cooled 
tubes,  as  they  are  generally  constructed,  cannot  be  used  in 
the  position  required  in  Shenton's  method,  for  the  reason  that 
the  water  would  flow  away  from  the  target  and  vapor  or  air 
collect  in  its  place. 

The  contents  of  the  intestines  in  front  of  the  kidneys  and  ureters 
may  cast  shadows  which  help  to  make  radiographs  of  this  region 
indistinct.  It  has  therefore  been  recommended  to  make  the  ex- 
posure after  the  intestines  have  been  emptied  as  nearly  as  possible 
by  purgatives  and  rectal  irrigations.  This,  however,  is  an  incon- 
venient and  unpleasant  procedure.  A  few  months  ago  Dr.  G. 
W.  Roberts,  of  New  York,  suggested  to  me  the  idea  of  com- 
pressing into  the  abdomen  over  the  region  of  the  kidney  a 
drum  of  material  transparent  to  the  rays,  for  the  purpose  of 


Fig.  83. — Compressing  the  abdomen  with  gas  ball  for  radiographing  kidneys, 

vertebrae,  etc. 

reducing  the  thickness  of  the  part  through  which  the  rays  may 
pass.  I  have  therefore  devised  two  or  three  methods  of  carry- 
ing out  this  suggestion.  One  of  these  methods  is  illustrated 
in  figure  83.  A  ball  of  very  thin  pure  rubber  rilled  with  air 
and  covered  by  fine  netting  is  compressed,  by  means  of  a  canvas 
band,  deeply  into  the  abdomen.  It  offers  very  little  obstruction 
to  the  ray  and  probably  compresses  the  contents  of  the  intes- 
tines from  those  portions  which  lie  underneath  the  ball.  It 
also  compresses  the  abdominal  wall  in  this  region,  and  in 
some  cases  the  thickness  of  the  part  of  the  body  through 
which  the  rays  pass  may  be  reduced  as  much  as  one-third. 
The  same  arrangement  can  be  used  with  advantage  sometimes 
in  radiographing  the  lumbar  vertebrae. 

Gall-stones. — Radiographs    showing    gall-stones    have    been 


1H1 


LOCALIZATION.  183 

obtained  by  a  number  of  operators,  but  it  is  fair  to  say  that 
success  in  this  work  is  obtained  in  a  very  small  percentage 
of  the  cases.  The  material  of  which  most  gall-stones  are  formed 
offers  very  little  obstruction  to  the  ray,  and  they  therefore 
cast  very  faint  shadows.  Moreover,  the  gall-bladder  is  so 
situated  that  in  order  to  cast  a  shadow  of  this  part  the  rays 
must  pass  through  other  viscera  of  considerable  density.  The 
best  position  is  to  place  the  patient  face  down  upon  the  plate, 
bending  the  body  backward  by  placing  supports  under  the 
thorax  and  pelvis.  This  tends  to  push  the  gall-bladder  below 
the  free  border  of  the  liver.  For  the  same  reason  it  has  been 
recommended  to  make  the  radiograph  during  full  inspiration. 
The  tube  should  be  placed  a  little  to  the  right  of  the  median 
line,  and  opposite  a  point  a  little  below  the  level  of  the  free 
border  of  the  liver. 

LOCALIZATION. 

The  exact  determination  of  the  position  of  foreign  objects 
in  the  body  by  means  of  the  x-ray  is  a  subject  to  which  a  great 
deal  of  work  has  been  devoted,  and  a  great  many  ingenious 
and  excellent  devices  for  this  purpose  have  been  invented 

A  single  radiograph  of  a  bullet  in  the  abdomen  gives  very 
little  information  as  to  its  depth  and  true  space  relations.  The 
simplest  method  of  determining  the  depth  would  be  to  make 
two  radiographs  from  directions  at  right  angles  to  each  other — 
an  antero-posterior  and  a  lateral  view,  for  example.  For  many 
cases  this  method  will  be  sufficiently  accurate,  but  it  must 
be  borne  in  mind  that  such  methods  will  never  be  exactly 
correct  unless  the  x-rays  pass  through  the  foreign  body  in  a 
direction  perpendicular  to  the  plane  of  the  plates — a  condition 
which  can  be  reached  only  approximately  in  practice,  unless 
the  body  can  be  located  first  with  the  fluoroscope.  There  are 
many  cases  in  which  this  will  be  impossible,  and  these  are 
the  very  cases  in  which  the  greatest  accuracy  is  necessary; 
for  example,  the  determination  of  the  position  of  small  frag- 
ments of  bullets  in  the  head,  and  of  small  pieces  of  steel  in 
the  eye. 

In  the  abdomen  it  may  be  perfectly  easy  to  obtain  an  antero- 


184  RADIOGRAPHY. 

posterior  view  of  a  bullet,  but  difficult  or  even  impossible  to 
show  it  in  a  lateral  view,  and  the  only  method  therefore  appli- 
cable to  such  a  case  is  to  make  two  antero-posterior  views 
with  the  tube  in  slightly  different  positions  and  determine  the 
position  of  the  foreign  body  by  triangulation. 

In  order  to  make  this  triangulation  it  is  necessary  to  know 
accurately  the  distance  of  the  source  of  the  ray  from  the  plate 
and  the  exact  position  on  the  plate  of  the  foot  of  a  perpendicular 
passing  through  the  source  of  the  x-ray.  It  is  convenient  to 
mark  with  a  piece  of  metal  wire  some  part  of  the  body  which 
is  in  direct  contact  with  the  plate.  The  position  of  the  shadow 
of  this  wire  will  be  the  same  in  any  position  of  the  tube,  and 
it  is  therefore  a  useful  "landmark." 

Mackenzie  Davidson  has  worked  out  a  very  beautiful  method 
of  doing  this  work.  This  apparatus  consists  essentially  of  a 
tube-holder  arrangement  which  enables  careful  measurements 
to  be  made  of  the  position  of  the  tube  with  reference  to  some 
known  object  on  the  plate.  Two  exposures  may  be  made  on 
the  same  plate,  with  thin  subjects,  but  when  the  part  is  thick  it 
will  be  better  to  use  separate  plates,  and  make  a  tracing  from 
both  plates  showing  the  change  in  the  position  of  the  shadows 
of  the  foreign  body  due  to  the  change  in  the  position  of  the 
tube.  This  method  was  described  in  an  article  in  the  Archives 
of  the  Rontgen  Ray,  an  abstract  of  which  is  given  below : 

"The  theory  of  the  method  is  essentially  this:  A  Crookes  tube 
is  placed  in  a  holder  which  can  slide  horizontally.  A  perpen- 
dicular is  dropped  from  the  point  in  the  anode  of  the  tube 
where  the  x-rays  originate  on  the  point  where  the  two  wires 
cross  each  other  at  right  angles,  and  one  of  the  wires  must 
be  parallel  to  the  horizontal  bar  along  which  the  tube-holder 
slides;  so  that  when  a  tube  is  displaced  along  the  bar  a  per- 
pendicular dropped  from  the  x-ray  point  in  the  anode  would 
always  fall  on  this  wire.  The  wires  in  reality  represent  two 
planes  at  right  angles  to  each  other,  the  photographic  plate 
representing  the  third  plane.  Eventually  I  obtain  the  three 
coordinates  of  the  foreign  body  from  the  three  planes  which 
are  at  right  angles  to  each  other  and  whose  relation  to  the 
part  of  the  patient's  body  skiagraphed  is  known. 


LOCALIZATION.  185 

"For  practical  purposes  it  is  convenient  to  have  the  wires 
stretched  across  a  flat  board  or  a  sheet  of  vulcanite,  which  can 
be  placed  on  the  table  in  the  correct  position  below  the  hori- 
zontal bar  and  fixed  on  the  table  by  means  of  drawing  pins. 
The  wires  being  inked  so  as  to  mark  the  skin,  a  photographic 
plate  enclosed  in  black  paper  in  the  usual  way  is  placed  beneath 
the  cross-wires.  The  perpendicular  distance  from  the  anode  to 
where  the  wires  cross  each  other  is  carefully  measured  and 
noted. 

"It  does  not  matter  very  much  to  what  distance  apart  the 
tube  is  to  be  displaced  in  order  to  take  the  two  skiagrams — 2£, 
5  inches  or  more  displacement  may  be  given.  Having  decided 
this,  the  movable  clips  are  so  placed  as  to  limit  the  sliding 
of  the  tube-holder  to  the  required  extent.  The  tube  is  then 
displaced  to  one  side,  and  the  patient  places  the  part  to  be 
photographed  on  the  cross-wires,  being  careful  not  to  move, 
once  the  skin  has  come  in  contact  with  the  wires,  because  it 
is  of  the  utmost  importance  that  the  shadows  of  the  cross- 
wires  on  the  negative  should  register  with  the  ink-mark  left 
on  the  patient's  skin.  Further,  it  is  convenient  to  put  a  small 
coin  on  one  corner  of  the  plate,  and  also  a  mark  on  the  patient's 
skin  nearest  it.  This  reminds  the  operator  as  to  the  relation 
of  the  plates  to  the  skin. 

"One  exposure  is  made,  and  the  tube  is  displaced  to  the 
other  side  up  to  the  clip,  and  a  second  exposure  is  given,  on 
the  same  plate  preferably,  or  upon  a  different  plate  provided 
a  suitable  apparatus  be  used  to  enable  the  plates  to  be  changed 
without  disturbing  the  position  of  the  parts  at  all. 

"Having  developed  and  fixed  the  negatives,  it  will  show  a 
single  shadow  of  the  cross-wires,  but  two  shadows  of  the  foreign 
body.  In  order  to  interpret  this  correctly  I  devised  the  follow- 
ing apparatus,  which  may  be  called  the  'cross-thread  localized 
(see  Fig.  85).  A  sheet  of  plate  glass  is  fixed  horizontally  having 
two  lines  marked  upon  its  surface  crossing  at  right  angles  in 
the  center.  A  mirror  hinged  below  it  allows  the  light  to  be 
reflected  from  below  so  as  to  render  details  of  the  negatives 
placed  upon  it  visible  by  transmitted  light. 

"A  scale  fastened  to  a  horizontal  bar  slides  up  and  down 


18G 


RADIOGRAPHY. 


on  two  rods  which  support  its  ends.  The  scale  has  small 
notches  opposite  its  marks.  This  is  so  placed  that  a  perpen- 
dicular dropped  from  the  0  or  middle  part  of  the  scale  falls 
exactly  where  the  lines  cross  on  the  glass  at  stage.  Further, 
the  edge  of  the  scale  is  parallel  to  the  line  running  right  and 
left  on  the  glass.  The  negative  is  now  placed  upon  the  glass 

stage,  being  careful  to 
?  bring  the  shadows  of  the 
cross-wires  into  register 
with  the  cross  on  the 
stage,  and  placed  with 
its  marked  quadrant  in 
correct  position.  The 
gelatin  surface  of  the 
plate  can  be  protected 
by  a  thin  transparent 
sheet  of  celluloid. 

"The  scale  is  now 
raised  or  lowered  so  as 
to  bring  the  0  to  pre- 
cisely the  same  distance 
above  the  negative  as 
the  anode  of  the  tube 
when  the  negative  was 
produced.  All  that  is 
now  necessary  is  to 
place  a  fine  silk  thread 
through  the  notch  on 
one  side  of  the  0  on 
the  scale  and  another 
thread  through  the 
notch  on  the  other  side 

exactly  the  same  distance  apart  as  that  which  measured  the 
displacement  of  the  x-ray  tube. 

"Small  weights  are  attached  to  the  ends  of  the  two  threads 
to  keep  them  taut,  while  the  other  ends  are  threaded  into 
fine  needles  fastened  to  a  piece  of  lead.  Thus  the  needle  with 
the  thread  can  be  placed  upon  any  point  of  the  negative  and 


Fig.    85. — Mackenzie   Davidson's  cross-thread 
local  izer. 


LOCALIZATION.  187 

remain  in  position.  In  short,  the  negative  is  now  relative  to 
the  cross-lines,  the  scale,  and  the  notches  from  which  the  two 
threads  come,  exactly  the  same  as  it  was  to  the  cross-wires 
with  Crookes  tube  when  being  produced. 

"A  needle  with  a  thread  is  placed  upon  any  point  on  one 
of  the  shadows  of  the  foreign  bodies,  and  the  other  needle 
is  placed  upon  a  corresponding  point  in  the  other  shadow, 
and  it  will  be  found  that  the  threads  cross  each  other,  just 
touching  and  no  more.  The  point  where  they  cross  represents 
the  position  of  the  foreign  body.  A  perpendicular  can  be 
dropped  from  this  point  to  the  negative  below,  and  a  mark 
made  at  the  point  where  it  touches  the  negative.  Then  with 
a  pair  of  compasses  the  distance  of  this  point  from  the  two 
cross-wires  can  be  measured. 

"The  height  of  the  point  where  the  threads  cross  gives  one 
coordinate;  that  is,  the  depth  of  the  foreign  body  below  the 
skin  which  rested  on  the  photographic  plate.  The  other  two 
measurements  give  the  other  two  coordinates.  It  will  be 
obvious  that  these  measurements  can  be  noted  thus. 

"As  the  mark  of  the  wire  is  left  on  the  patient's  skin,  all 
that  is  required  is  to  measure  the  two  coordinates  on  the  skin 
that  give  the  point  below  which  the  foreign  body  will  be  found 
at  the  depth  given  by  the -third  coordinate."* 

Davidson  has  applied  this  method  to  determine  the  position 
of  foreign  bodies  in  the  eye. 

Dr.  Cowl,  of  Berlin,  has  recently  published  a  new  method 
of  locating  foreign  bodies  in  the  eye  which  consists  in  making 
one  lateral  view  through  the  side  of  the  head  and  another 
with  the  plate  placed  in  the  mouth,  and  the  tube  placed  directly 
over  the  head  so  that  the  shadow  is  cast  downward  upon  the 
plate  and  therefore  shows  the  antero-posterior  distance.  In 
using  this  method  it  is,  of  course,  necessary  to  place  on  the 
orbit  or  in  some  position  near  it  wires  or  pieces  of  metal  which 
may  be  used  as  guides  in  making  measurements.  The  shadow 
will  then  show  the  position  of  the  foreign  body  with  reference 
to  these  metallic  markers. 

In  locating  foreign  bodies  in  the  eye  it  is  important  to  prevent 

*  Archives  of  the  Rontgen  Ray,  May,  1898. 


188 


RADIOGRAPHY. 


rotation  of  the  orbit  while  exposure  is  being  made.  This  will 
be  accomplished  by  having  the  patient  look  steadily  at  a  fixed 
object  several  feet  in  front  of  him. 

In  practice  it  is  exceedingly  difficult  to  make  measurements 
of  the  position  of  a  tube  with  a  tape-line  or  scale  which  are 
sufficiently  accurate  for  use  in  determining  the  depth  of  a 
body  by  triangulation.  To  assist  in  determining  the  exact  posi- 
tion of  the  tube  I  have  been  using  for  several  years  the  simple 
apparatus  which  is  shown  in  figure  86;  it  consists  of  two  or 
more  metal  rods  which  are  pointed  at  each  end  and  held  in 
a  framework  of  wood  or  aluminum  in  such  a  way  that  they 
can  be  placed  on  a  plate,  and  will  be  exactly  perpendicular  to 


Fig.  86. — Wooden  block  containing  pointed  metal  rods,  for  use  in  determining 
position  of  source  of  x-ray  in  locating  foreign  bodies. 


it.  When  the  radiograph  is  made,  these  two  metal  rods  will 
cast  pointed  shadows  on  the  plate  which  make  an  angle  with 
each  other.  Xow,  if  lines  be  drawn  through  the  points  of  these 
shadows  they  will  intersect  in  a  point  which  lies  at  the  foot 
of  the  perpendicular  through  the  source  of  the  x-ray.  The  dis- 
tance of  the  source  of  the  x-ray  may  be  measured  with  fair 
accuracy  by  measuring  with  a  tape-line  the  distance  from  the 
center  of  the  target  to  the  plate,  but  it  may  also  be  determined 
by  calculating  the  altitude  of  the  right-angled  triangle  whose 
base  is  a  line  between  the  foot  of  the  perpendicular  and  the 
end  of  the  shadow  of  one  of  these  metal  rods.  This  triangle 
will  be  similar  to  the  triangle  whose  base  is  the  shadow  of 


LOCALIZATION. 


189 


the  rod  and  whose  altitude  is  the  length  of  the  rod,  both  of 
which  factors  are  known.  If  the  two  exposures  are  made  on 
the  same  plate,  the  localization  may  be  made  very  readily  by 
using  the  Mackenzie  Davidson  cross-thread  apparatus,  adjusting 
the  support  of  the  cross-threads  directly  over  the  two  points 
on  the  plate  which  mark  the  sources  of  the  x-ray,  and  by  carrying 
the  lower  ends  of  the  threads  to  similar  points  in  the  two  shadows 
of  the  foreign  bodies.  If  the  exposures  are  made  on  separate 
plates,  it  will  be  necessary  to  make  a  tracing  which  shows 
the  two  sources  of  the  x-ray,  the  two  shadows  of  the  foreign 


Fig.  87. — Diagram  illustrating  method  of  localization. 

body,  and  the  guide  marker  which  is  placed  in  contact  with 
the  plate,  and  whose  shadow  occupies  the  same  position  in 
both  exposures.  This  guide  mark  is  necessary  in  order  to 
adjust  the  tracing  to  proper  relation  with  the  two  plates. 

The  determination  of  space  relation  of  the  body  with  refer- 
ence to  the  plate  may  also  be  made  by  simple  graphic 
methods  which  will  be  obvious.  A  general  idea  of  how  the 
shadows  enable  the  sources  of  x-ray  and  the  position  of  the 


190 


RADIOGRAPHY. 


foreign  body  to  be  determined  is  shown  in  figures  87  and  88. 
In  order  to  refer  the  measurements  on  the  plate  to  the  surface 
of  the  body  it  will  be  necessary  to  place  on  some  part  of  the 
skin  which  is  in  contact  with  the  plate  a  mark  whose  position 
is  shown  in  both  plates.  The  mark  on  the  skin  may  be  made 
with  tincture  of  iodin  or  silver  nitrate  which  will  remain  after 
the  part  has  been  scrubbed  for  operation.  If  this  mark  is 
covered  with  a  small  piece  of  lead  wire  held  in  position  by 
surgeon's  plaster,  its  position  will  be  shown  on  the  photographic 
plate,  and  measurements  can  be  referred  to  it. 

Apparatus  and  methods  for  localization  depending  on  the 
same  principles  have  been  devised  by  Borrell  and  others. 


Fig.  88. — Plan  illustrating  method  of  localization. 

Stereoscopic  Radiographs. — It  was  pointed  out  by  Elihu 
Thomson  in  1896  that  two  radiographs  of  an  object  made 
by  displacing  the  source  of  x-ray  through  a  horizontal  dis- 
tance of  about  2|  inches  with  the  tube  about  10  inches  from 
the  plate,  would,  when  viewed  through  a  stereoscope,  give  the 
appearance  of  relief.  The  value  of  such  radiographs  in  showing 
the  position  of  fragments  of  fractured  bone  or  of  a  foreign 
object  in  the  body  will  be  obvious. 

Mackenzie  Davidson  worked  out  a  practical  method  of 
making  such  radiographs  and  used  the  Wheatstone  stereoscope 
for  viewing  them. 


STEREOSCOPIC   RADIOGRAPHS.  191 

In  making  stereoscopic  radiographs  great  care  must  be  exer- 
cised in  two  or  three  details.  The  two  exposures  must  be  made 
without  any  change  in  the  position  of  the  subject.  This  necessi- 
tates supporting  it  upon  a  thin  substance  which  is  transparent 
to  the  x-ray  beneath  which  plates  may  be  inserted  or  removed 
without  disturbing  the  object.  The  two  radiographs  must  be  ad- 
justed to  a  common  level,  which  is  as  nearly  as  possible  parallel 
with  the  line  through  which  the  source  of  x-ray  is  moved  in  the 
two  exposures.  Radiographs,  unlike  most  photographs,  rarely 
show  points  from  which  they  can  be  accurately  leveled,  and 
it  is  therefore  necessary  to  produce  an  artificial  base-line  by 
which  they  can  be  placed  in  the  proper  position  for  the  stereo- 
scope. The  wrappings  ordinarily  used  for  x-ray  plates  are 
considerably  larger  than  the  plate,  allowing  considerabe  shifting 
within  them,  hence  it  is  impossible  to  use  the  edge  of  the  plate 
as  a  base-line.  I  have  developed  at  the  Edward  N.  Gibbs 
X-ray  Laboratory  an  appliance  shown  in  figure  89  for  making 
stereoscopic  radiographs.  The  object  to  be  radiographed  is 
supported  by  a  sheet  of  celluloid  about  T^-  of  an  inch  thick 
stretched  between  supports  on  the  base.  On  the  base  is 
a  V-shaped  guide  on  which  slides  a  block  carrying  the  tube- 
holder.  A  scale  measures  the  distance  through  which  the 
tube-holder  is  moved.  Underneath  the  celluloid  sheet  and 
resting  upon  the  plate  is  a  strip  of  copper  held  loosely  by  two 
pins  in  such  a  way  that  its  edge  remains  always  parallel  with 
the  V-shaped  guide,  and  therefore  with  the  line  through  which 
the  x-ray  tube  is  moved.  The  tube-holder  is  in  many  respects 
like  the  one  shown  in  figure  63,  but  it  is  supported  on  a  block 
which  slides  on  a  V-shaped  guide  fastened  to  the  base. 

In  using  the  apparatus  the  subject  is  supported  by  the  celluloid 
sheet,  the  plate  is  slipped  underneath  this  sheet  and  under 
the  copper  strip  so  that  the  edge  of  the  copper  strip  casts  a 
shadow  at  the  margin  of  the  plate.  The  tube  is  adjusted  in 
such  a  way  as  to  obtain  a  good  radiograph  of  the  part.  The 
exposure  is  made,  the  plate  is  removed,  and  another  one  inserted 
in  its  place,  and  the  tube-holder  moved  by  means  of  the  sliding 
block  through  the  desired  distance,  which  will  be  indicated  on 
the  scale.  Another  exposure  is  made  in  the  same  way.  The 


192 


RADIOGRAPHY. 


copper  strip  above  referred  to  is  perforated  at  two  or  three 
points  with  small  apertures  whose  shadows  enable  corresponding 
points  on  the  two  plates  to  be  referred  to  each  other.  This 
apparatus  may  also  be  used  with  great  advantage  in  making 


Fig.  89. — Apparatus  for  making  radiographs  for  use  with  the  stereoscope  or  for 
location  of  foreign  bodies. 

two  exposures  for  locating  foreign  bodies  after  the  method 
described  above.  In  fact,  two  stereoscopic  plates  may  be  used 
with  Mackenzie  Davidson's  localizer  for  this  purpose.  Localiza- 
tion, however,  will  be  more  accurate  if  tube  is  moved  through 


STEREOSCOPIC    RADIOGRAPHS. 


193 


a  greater  distance  than  will  be  advisable  for  obtaining  stereo- 
scopic effects. 

Owing  to  the  large  size  of  plates  necessary  for  radiographic 
work,  stereoscopic  radiographs  must  be  viewed  through  some 
special  form  of  stereoscope,  or  reduced  to  proper  size  for  the 
ordinary  stereoscope.  For  the  ordinary  stereoscope  the  picture 
should  not  exceed  2^  inches  in  width,  and  the  reduction  of 
large  radiographs  to  this  size  takes  a  great  deal  of  time  and 
trouble.  Wheatstone 's  stereoscope  is  almost  universally  em- 
ployed for  observing  the  large  pictures. 

Two  excellent  types  of  this  stereoscope  have  been  devised 
by  Dr.  L.  A.  Weigel,  of  Rochester,  and  Dr.  Alexander  B.  Johnson, 
of  New  York  city.  The  Wheatstone  stereoscope  consists  of  two 


Fig.  90. — "Weigel's  modification  of  the  Wheatstone  stereoscope. 

mirrors  placed  at  right  angles  to  each  other,  with  an  arrange- 
ment for  supporting  the  pictures,  so  that  an  observer  who 
places  his  eyes  opposite  the  two  mirrors  will  see  one  picture 
with  one  eye  and  the  other  picture  with  the  other  eye.  Dr. 
Weigel's  arrangement  (see  Fig.  90)  has  a  very  good  means 
for  varying  the  intensity  of  the  light,  by  shifting  the  distance 
of  the  incandescent  lamp  from  the  negative,  which  accomplishes 
the  result  without  any  change  in  the  color  of  the  light  and 
enables  two  negatives  of  unequal  density  to  be  equally  illum- 
inated. Dr.  Johnson's  instrument  has  a  bellows,  which  excludes 
reflected  light  from  the  negative  and  therefore  makes  it  possible 
to  use  the  apparatus  in  a  room  not  completely  darkened. 

13 


194  RADIOGRAPHY. 

Interpretation  of  the  Negative. — Radiographs  differ  in  many 
essentials  from  other  pictures,  and  skill  in  interpreting  them 
can  be  acquired  only  by  considerable  experience.  It  may  be 
useful  here  to  mention  a  few  points  which  must  always  be 
considered.  It  has  been  stated  before  that  a  radiograph  must 
always  be  considered  as  a  shadow  of  the  part,  and  not  as  a 
picture.  In  a  good  radiograph  the  shading,  due  to  varying 
thickness  and  varying  penetrability  of  different  parts  of  the 
subject,  often  gives  an  appearance  of  perspective  which  may 
be  quite  misleading.  A  little  practice  with  the  skeleton  and 
incandescent  lamp  mentioned  in  the  earlier  part  of  the  chapter 
will  often  be  of  great  value  in  helping  correctly  to  interpret 
a  radiograph. 

In  cases  of  fracture  and  dislocation  in  which  the  mere  idea 
of  position  is  all  that  is  sought  the  interpretation  will  be  fairly 
easy,  but  for  determining  the  nature  of  diseased  conditions 
much  more  judgment  will  be  required. 

Malignant  diseases  of  the  bone  invariably  cause  them  to 
become  more  transparent,  the  ray  thus  producing  in  the  negative 
dark  spots,  and  in  the  print  light  spots.  In  nearly  all  advanced 
malignant  growths  of  the  bone  a  pushing-out  of  the  periosteum 
will  be  shown.  In  tubercular  bones  there  will  be  greater  trans- 
parency and  a  peculiar  lack  of  contrast  of  the  bones  with  the 
flesh  which  will  be  readily  recognized  with  a  little  practice. 
Very  often  in  bone  injuries  of  long  standing  there  will  be  an 
increase  of  transparency  due  to  a  thinning  of  the  compact 
tissue  which  results  from  a  lack  of  nutrition.  In  these  cases 
it  may  sometimes  be  difficult  to  distinguish  between  a  tubercular 
bone  and  one  in  which  there  is  atrophy  due  to  lack  of  nutrition. 
In  bone  atrophy  there  is  less  disturbance  of  the  structure  of 
the  cancellous  tissue. 

Careful  attention  to  methods  of  localization  will  prevent 
errors  in  determining  the  position  of  foreign  bodies  by  the 
x-ray. 


CHAPTER  VII. 

THE  PHOTOGRAPHIC  MATERIALS  AND  THEIR 
MANIPULATION. 

IT  is  probably  true  that  as  many  unsatisfactory  radiographs 
are  due  to  improper  manipulation  of  the  photographic  plate 
as  to  improper  exposures  to  the  x-ray.  Some  radiographers 
entrust  the  development  of  their  plates  to  the  professional 
photographer  or  to  a  more  or  less  unskilled  assistant.  Occa- 
sionally one  may  find  a  photographer  who  is  skilful  enough 
and  careful  enough  to  obtain  good  results  from  x-ray  exposures, 
but  such  men  are  rare  exceptions.  In  order  to  obtain  the 
best  results,  as  well  as  to  avoid  annoying  delays,  risk  of  breakage, 
etc.,  it  is  necessary  for  the  Rontgen  worker  to  develop  his 
own  plates,  or  at  least  to  have  them  developed  by  a  skilled 
assistant  under  his  immediate  direction.  The  development  of 
a  radiograph  does  not  differ  in  many  respects  from  that  of 
an  ordinary  photograph,  and  as  there  are  so  many  excellent 
books  on  photographic  development,  I  shall  take  up  here  only 
a  few  points  which  relate  especially  to  radiographic  work. 

Plates. — Any  good  photographic  dry  plate  is  suitable  for 
radiographic  work,  and  there  is  very  little  choice  between  the 
best  grades  of  the  plates  of  the  best  makers.  The  rapidity 
of  dry  plates  for  x-ray  exposures  bears  some  relation  to  their 
rapidity  for  camera  exposures,  but  for  the  x-ray  there  is  not 
so  great  a  difference  between  the  very  fast  and  the  very  slow 
plates.  The  best  results  seem  to  be  obtained  on  plates  of 
medium  or  fast  speed,  such  an  "  Hammer  Extra  Fast,"  "Cramer 
Banner,"  "Seeds  26X  or  27."  Double  coated  plates  offer  some 
advantage,  and  these  are  sold  usually  as  non-halation  plates  by 
most  of  the  makers.  The  Hammer  Aurora  I  have  found  to 
give  excellent  results  where  it  is  desirable  to  use  a  double 
coated  plate.  With  the  double  coated  plates  there  is  some 
gain  in  the  matter  of  shortening  the  exposure,  and  apparently 

195 


196      PHOTOGRAPHIC  MATERIALS  AND  THEIR  MANIPULATION. 

there  is  greater  differentiation  of  the  tissues  when  they  are 
used  for  radiographing  the  thicker  parts  of  the  body;  for  ex- 
ample, in  cases  of  renal  calculus,  etc.  Celluloid  films  may 
often  be  used  with  advantage  for  x-ray  work,  but  they 
have  not  the  keeping  qualities  of  glass  plates,  and  for  this 
reason  are  not  so  reliable.  Celluloid  film,  however,  has  the 
advantage  of  being  exceedingly  transparent  to  the  x-ray,  and 
because  of  this  and  because  of  its  thinness  it  is  quite  feasible 
to  enclose  a  film  between  two  intensifying  screens  and  thus 
reduce  the  exposure  more  than  is  possible  with  a  single  intensi- 
fying screen  and  a  glass  plate.  In  Germany  these  films  are 
made  by  Schleussner  for  x-ray  work,  having  a  double  coat  on 
each  side,  making  in  all  four  coats.  Such  films  are  intended 
to  be  used  between  two  intensifying  screens  as  described  above. 
The  development  of  such  films  is  exceedingly  tedious  and 
requires  arrangements  which  more  than  compensate  for  the 
gain  in  speed  obtained. 

For  radiographing  the  teeth  it  is  very  convenient  to  use  a 
celluloid  film  encased  in  a  water-tight  covering  and  placed 
in  the  mouth  as  mentioned  in  Chapter  VI.  For  this  purpose 
the  Seeds  double  and  triple  coated  films  are  very  well  adapted, 
and  are  much  better  than  the  thinner  roll  films  supplied  for 
hand  cameras.  The  very  fast  bromide  papers  may  also  be 
used  instead  of  plates,  thus  giving  prints  directly.  They  offer 
so  little  obstruction  to  the  ray  that  a  dozen  or  more  of  them 
may  be  laid  up  in  a  pile  and  exposed  all  at  once.  The  bottom 
sheet  will  give  about  as  good  a  picture  as  the  top  one.  These 
bromide  papers,  however,  do  not  give  as  good  results  as  may 
be  obtained  on  films  or  glass,  and  their  use  is  not  recommended. 
Several  makers  put  out  x  -ray  plates,  or  plates  especially  in- 
tended for  x-ray  work.  I  have  not  found  any  of  these,  however, 
which  present  any  advantage  over  the  regular  photographic 
plates,  and  I  prefer  not  to  use  them,  for  the  reason  that  the 
demand  for  them  is  comparatively  small  and  consequently 
they  are  liable  to  become  old  before  the  dealer  disposes  of 
them. 

It  is  very  important  that  the  plates  or  films  used  in  radio- 
graphic  work  should  be  fresh,  and  it  is  much  easier  to  obtain 


SIZE    OF   THE    PLATES — DEVELOPERS.  197 

fresh  plates  of  the  sort  which  are  used  for  general  photographic 
work  than  of  those  which  are  sold  only  for  x-ray  work. 

Size  of  the  Plates. — For  convenience  in  filing  away  and  pre- 
serving the  negatives  it  is  well  to  adopt  a  few  standard  sizes, 
and  to  use  always  one  of  these  sizes.  The  size  to  be  used 
will  be  determined,  of  course,  principally  by  the  parts  to  be 
radiographed,  but  it  is  a  good  idea  to  adopt  the  sizes  which 
are  in  greatest  demand  for  camera  work.  These  sizes  are  the 
ones  which  are  most  readily  obtained  fresh.  It  happens  that 
nearly  all  of  my  work  is  done  on  two  sizes  of  plates:  viz.,  8  X  10 
and  11  X  14.  In  addition  to  these  sizes  I  have  always  on 
hand  plates  5X8,  and  14  X  17.  Practically  all  of  my  work 
is  done  on  plates  of  these  four  sizes.  Occasionally  a  plate 
18  X  22  is  used,  but  such  a  size  is  rarely,  if  ever,  necessary. 
Consideration  of  expense  naturally  leads  one  to  use  as  small 
a  plate  as  possible,  but  it  is  as  well  not  to  carry  this  point  too 
far.  Development  is  easier  when  there  is  a  reasonably  good 
margin  outside  of  the  picture,  and  by  using  a  large  plate  very 
often  we  may  detect  an  injury  which  was  out  of  the  region 
in  which  the  trouble  was  suspected. 

Keeping  the  Plates. — It  must  be  borne  in  mind  that  the 
x-ray  passes  through  walls,  and  doors,  and  boxes,  and  that 
if  a  stock  of  photographic  plates  is  kept  within  thirty  or  forty 
feet  of  the  room  in  which  powerful  x-ray  tubes  are  used  fre- 
quently, it  is  as  well  to  protect  them  against  stray  rays.  For 
this  purpose  I  use  a  wooden  box  or  cupboard,  covered  on  the 
outside  with  ordinary  plumbers'  sheet-lead  to  the  thickness  of 
about  |  of  an  inch.  The  plates  are  less  liable  to  be  scratched 
or  damaged  if  kept  standing  on  edge.  The  cupboard  is  there- 
fore provided  with  vertical  partitions  and  shelves  to  accommo- 
date the  plates  of  different  sizes.  Two  compartments  are 
reserved  for  the  plates  which  have  been  placed  in  the  envelopes 
ready  for  exposure,  and  for  the  exposed  plates  which  await 
development. 

Developers. — There  are  so  many  good  developers  that  it 
is  impossible  to  say  which  is  the  best  for  x-ray  negatives.  In 
a  general  way,  it  may  be  stated  that  those  developers 
which  give  contrast  are  usually  to  be  preferred.  This 


198      PHOTOGRAPHIC  MATERIALS  AND  THEIR  MANIPULATION. 

property  may  lie  in  the  developing  agent  itself,  or  it  may 
be  due  partly  to  the  proportions  of  various  ingredients  used 
in  the  developing  mixture.  It  is  well  to  become  accustomed 
to  one  good  developer  and  not  to  change.  It  may  be  truly 
said  that  the  developer  is  best  which  one  knows  best  how 
to  use.  Undoubtedly  the  best  results  in  radiographic  work  are 
obtained  with  slow  development,  although  excellent  results 
are  obtained  by  many  workers  with  more  rapid  developers, 
such  as  metol,  rodinal,  etc.  My  own  preference  is  for  pyro- 
gallol,  which  I  mix  according  to  the  following  formula. 
Formula. — 

Solution  No.  1 : 

Distilled  water 24  oz. 

Oxalic  acid 15  gr. 

Pyrogallic  acid 1  oz. 

Solution  No.  2: 

Sodium  sulphite  solution,  sp.  g.  80. 
Solution  No.  3: 

Sodium  carbonate  solution,  sp.  g.  40 

To  develop  take: 

Solution  No.  1 1  part 

Solution  No.  2 1  part 

Solution  No.  3 1  part 

Water 2  to  4  parts. 

In  Germany  some  of  the  best  workers  prefer  glycinamid. 
The  formula  recommended  by  von  Ziemssen  and  Reider,  who 
have  done  some  of  the  fastest  and  best  radiographic  work 
that  has  as  yet  appeared,  is  as  follows: 

(a)  Glycin 40.0 

Potassium  carbonate 40.0 

Sodium  sulphite      loO.O 

Distilled  water,  hot 1000.0 

(b)  Potassium  carbonate 100.0 

Distilled  water 1000.0 

For  use,  mix  equal  parts  a  and  6. 

The  advantage  of  glycin  is  that  development  with  it  may 
be  carried  to  almost  any  extent  without  producing  fog.  It  is 
very  slow  in  its  action,  and  some  workers  use  it  in  a  vertical 
tank  very  much  diluted,  leaving  their  plates  in  this  dilute 


DEVELOPERS.  199 

developer  for  from  one  to  three  hours.  If  the  plate  is  properly 
exposed,  it  may  be  immersed  in  the  developer  and  removed 
at  the  end  of  two  hours  with  good  results.  Obviously,  though, 
it  is  much  safer  to  watch  the  plate  during  development,  or 
at  least  to  look  at  it  from  time  to  time. 

Prepared  developers  are  not  to  be  recommended  for  radio- 
graphic  work.  It  is  much  better  to  buy  the  purest  chemicals 
obtainable  and  to  make  the  developer  yourself  with  distilled 
water.  It  is  especially  important  to  obtain  pure  sodium  sul- 
phite. This  important  ingredient  of  almost  every  developer 
is  very  liable  to  contain  impurities,  principally  sodium  car- 
bonate, in  varying  amounts.  In  order  to  obtain  uniform 
results,  therefore,  it  is  necessary  to  use  the  best  chemicals 
obtainable  and  to  use  always  the  brand  to  which  one  is  accus- 
tomed. Good  negatives  are  obtained  by  so  many  widely 
different  methods  of  development,  and  so  many  developers, 
that  it  is  impossible  to  mention  them  all  here.  It  will  be 
sufficient  to  describe  one  method  of  development  with  one 
developer:  viz.,  pyrogallol.  Referring  to  the  formula  given 
above,  it  will  be  seen  that  three  stock  solutions  are  called 
for.  These  should  be  kept  in  glass  bottles  with  well-ground 
stoppers,  and  these  bottles  should  never  be  allowed  to  become 
nearly  empty.  The  pyro  solution  (No.  1)  is  especially  liable 
to  deteriorate  by  contact  with  the  air.  The  addition  of  the 
oxalic  acid,  however,  helps  to  preserve  it,  and  in  tightly  stop- 
pered bottles  it  may  be  kept  for  a  week  or  two  in  good  condition. 

In  mixing  the  carbonate  and  sulphite  solutions  for  a  devel- 
oper, the  hydrometer  will  be  found  to  give  more  accurate 
results  than  can  be  obtained  by  weighing  the  chemicals.  A 
convenient  way  is  to  keep  on  hand  glass-stoppered  bottles 
full  of  saturated  solutions  of  the  sodium  carbonate  and  sul- 
phite. When  it  is  desired  to  make  up  solutions  No.  2  and  No. 
3,  these  saturated  solutions  are  diluted  in  a  graduate  with 
water  until  the  proper  hydrometer  reading  is  obtained.  The 
stock  solution  bottle  is  then  filled  from  the  graduate  and  the 
bottles  containing  the  saturated  solution  are  filled  completely 
by  the  remaining  liquid  in  the  graduate  and  the  addition  of 
more  water  and  salts. 


200       PHOTOGRAPHIC  MATERIALS  AND  THEIR  MANIPULATION. 

Developing  the  Plates. — The  temperature  of  the  developer  is 
a  matter  of  great  importance.  If  it  is  too  warm,  the  plates 
are  likely  to  fog;  and  if  too  cold,  the  development  proceeds 
very  slowly.  If  possible,  the  temperature  should  not  be  allowed 
to  vary  beyond  the  limits  of  65°  and  70°  F.  In  the  summer- 
time it  may  be  often  found  necessary  to  cool  the  developer 
with  ice.  This  may  be  done  by  putting  a  little  cracked  ice 
in  the  solution,  but  a  better  way  is  to  ice  the  developer  in 
the  bottle,  after  the  manner  of  a  bottle  of  champagne,  until 
the  temperature  is  60°  F.  The  temperature  of  the  solution 
will  quickly  rise  to  65°  or  68°  F.  when  it  is  poured  upon  the 
developing  tray  and  the  plate,  which  are  somewhat  warmer. 

In  developing  the  dry  plate  it  should  be  borne  in  mind  that 
it  takes  some  little  time  for  the  liquids  to  soak  up  the  emulsion 
so  that  the  developing  agent  can  reach  all  of  the  silver  salts 
in  the  film.  If  we  start  developing  with  a  strong  solution, 
the  superficial  parts  of  the  film  which  are  first  exposed  to  the 
action  of  the  developer  will  be  acted  upon  before  the  solution 
has  a  chance  to  reach  the  deeper  parts.  It  is  therefore  my 
practice  to  begin  development  with  a  solution  containing  Nos. 
1  and  2,  and  very  little  carbonate.  With  this  mixture  develop- 
ment is  continued  for  about  six  to  ten  minutes,  during  which 
time  the  emulsion  will  have  become  soaked  up.  The  carbonate 
of  soda  is  then  added  in  small  portions  from  time  to  time  as 
the  development  proceeds.  If  the  plate  is  over-exposed,  only 
a  small  amount  of  carbonate  will  be  needed.  Restraining  the 
development  by  reducing  the  amount  of  carbonate  seems  to 
give  better  results  than  the  use  of  bromide  of  potassium,  al- 
though in  cases  of  over-exposure  it  will  be  necessary  to  use 
bromide  with  plenty  of  carbonate  in  order  to  obtain  the  best 
results.  Development  is  continued  in  this  way  for  from  fifteen 
to  fifty  minutes,  keeping  the  solution  moving  by  rocking  the 
tray  and  keeping  a  close  wratch  on  the  progress  of  develop- 
ment. With  an  x-ray  negative  development  may  be  continued 
for  a  much  longer  period  than  would  be  advisable  with  a  camera 
exposure,  and  the  usual  error  of  the  professional  photographer 
in  developing  an  x-ray  negative  is  that  of  under-development. 
The  problem  of  determining  just  when  development  has  been 


FIXING   BATHS.  201 

carried  far  enough  is  an  exceedingly  difficult  one.  It  is  a  thing 
which  must  be  acquired  by  practice  and  about  which  written 
directions  are  of  little  use.  In  order  to  obtain  sufficient  density 
of  the  negative  it  is  usually  necessary  to  proceed  with  develop- 
ment until  the  plate  is  perfectly  opaque  to  the  ordinary  ruby 
light  of  the  dark-room  lamp.  Success  in  the  development  of 
x-ray  negatives  requires  a  great  amount  of  patience  and  skill. 
This  part  of  the  work  is  not  less  important  than  that  of  making 
the  exposure,  and  must  be  attended  to  with  the  same  care  that 
is  needed  for  the  other  part  of  the  work. 

Fixing  Baths. — After  the  development  is  complete  the  plate 
should  be  washed  two  or  three  minutes  in  several  changes 
of  water  and  then  placed  in  the  fixing  bath.  The  ordinary 
fixing  bath  is  simply  a  solution  of  about  one  part  of  sodium 
hyposulphite  to  four  or  five  of  water.  Such  a  fixing  solution 
does  not  keep  long  and  must  be  renewed  frequently.  Some 
photographers  use  with  the  hypo  solution  an  alum  mixture, 
for  the  purpose  of  preserving  the  solution  and  hardening  the 
film.  The  formula  of  one  of  these  alum  baths  is  given  below : 

(a)  Water 96  oz. 

Hypo 2  Ibs. 

Seeds'  c.  p.  sulphite  of  soda 2  oz. 

(b)  Water 32  oz. 

Chrome  alum 2  oz. 

Sulphuric  acid J  oz. 

Pour  b  into  a,  while  stirring  a  rapidly.  As  the  chrome  alum  dissolves  slowly, 
a  stock  solution  of  b  can  be  made  up. 

These  alum  baths  are  more  or  less  unstable,  and  chemical 
changes  sometimes  occur  in  them  which  produce  bad  effects 
upon  the  plates.  The  most  convenient  fixing  solution  I  have 
found  consists  of  the  sodium  hyposulphite  solution,  about 
1:4,  to  which  is  added  one  ounce  of  a  saturated  solution  of 
sodium  bisulphite  (acid  sulphite  of  soda)  to  16  ounces  of  the 
hypo  solution.  Such  a  bath  will  remain  clear  for  a  long  time 
(I  change  mine  about  once  a  month),  and  it  has  a  hardening 
effect  on  the  film.  The  fixing  process  will  require  usually  from 
five  to  twenty  minutes.  With  the  double  coated  plates,  the 
time  required  for  thorough  fixing  is  long.  Plates  should  be 


202       PHOTOGRAPHIC  MATERIALS  AND  THEIR  MANIPULATION. 

allowed  to  remain  in  the  fixing  bath  for  two  or  three  minutes 
after  every  trace  of  unreduced  silver  salts  has  disappeared 
from  the  film.  They  should  be  then  washed  in  running  water 
for  forty  to  fifty  minutes,  when  they  are  ready  to  dry.  In  drying 
plates  it  is  well  to  remember  that  the  water  drains  from  them 
better  if  thy  are  supported  in  such  a  manner  that  one  corner 
is  lowest. 

The  Dark  Room. — The  development^  the  small  plates  which 
are  used  in  the  ordinary  hand  camera  may  be  done  conveniently 
in  a  dark  closet  or  in  any  room  that  can  be  properly  darkened, 
but  when  the  large  plates  necessary  for  radiographic  work  are 
used  it  is  very  desirable  to  have  plenty  of  room.  Running 
water  is  almost  indispensable  to  the  dark  room,  and  it  is 
very  convenient  to  have  a  large  soapstone  sink,  large  enough 
to  contain  a  number  of  developing  trays  at  once,  so  that  several 
plates  may  be  developed  at  the  same  time.  The  sink  is  much 
preferable  to  a  table  for  holding  the  developing  trays  for  obvious 
reasons.  Next  to  the  running  water,  perhaps,  the  greatest 
comfort  in  the  dark  room  is  an  electric  light  circuit.  The 
uncertainty  of  oil  lamps,  the  necessity  for  trimming  and  refilling 
them,  their  variations  in  intensity,  and  the  unavoidable  odor 
are  points  which  need  only  be  mentioned.  The  light  of  an 
incandescent  lamp  is  comparatively  constant,  requires  the 
minimum  attention,  and  does  not  vitiate  the  air  of  the  dark 
room. 

Figure  91  shows  a  ruby  lamp  which  I  have  designed  for 
the  dark  room  of  the  Edward  N.  Gibbs  X-ray  Laboratory 
and  which  has  been  very  satisfactory.  Two  16-candle-power 
incandescent  lamps  of  ruby  glass  are  enclosed  in  a  wooden 
box  with  an  asbestos  lining.  One  face  of  this  box,  which  is 
8  by  10  inches,  is  covered  with  a  plate  of  ruby  glass,  a  plate 
of  orange  glass,  and  lastly  a  plate  of  ground  glass.  The  box 
is  supported  so  that  is  may  be  rotated  on  its  horizontal  axis 
or  a  vertical  axis.  It  thus  has  all  the  movements  of  a  search- 
light, and  its  light  may  be  directed  to  various  parts  of  the 
dark  room  or  upon  the  plates,  or  away  from  the  plate  toward 
the  wall.  It  is,  of  course,  desirable  to  expose  the  plates  as 
little  as  possible  even  to  the  ruby  light,  and  the  advantage 


THE    DARK    ROOM. 


203 


of  being  able  conveniently  to  turn  the  light  from  the  plates 
will  be  apparent.  In  addition  to  these  movements  of  rotation, 
this  ruby  lamp  is  arranged  to  slide  backward  and  forward 
along  a  wooden  track,  which  is  held  by  brackets  above  the 
developing  sink  along  its  whole  length.  It  may  thus  be  moved 
in  various  positions  to  examine  any  one  of  trays  in  which  the 
process  of  development  is  going  on.  The  rocking  of  the  develop- 
ing trays  during  a  long  tedious  development  becomes  very 


Fig.  91. — Ruby  light  for  dark  room. 

tiresome,  and  a  number  of  automatic  rocking  devices  have 
been  used.  One  of  the  simplest  is  that  in  which  the  support 
for  the  tray  is  connected  with  a  long  heavy  pendulum,  which 
when  once  set  in  motion,  continues  to  swing  for  a  considerable 
time.  Some  operators  use  a  vertical  developing  bath  instead  of 
trays,  and  place  in  it  a  number  of  plates,  circulating  the  liquid; 
by  various  means. 


204      PHOTOGRAPHIC  MATERIALS  AND  THEIR  MANIPULATION. 

If  only  a  few  plates  are  to  be  developed,  the  fixing  solution 
may  be  used  in  an  ordinary  developing  tray;  but  if  it  is  desired 
to  fix  several  plates  at  a  time,  it  is  a  great  convenience  to  have 
a  vertical  fixing  bath  slotted  to  hold  the  plates  of  various  sizes 
and  provided  with  a  cover  which  may  be  closed  to  exclude 
the  light  after  developing  is  finished.  For  washing  the  plates 
a  slate  or  metal-lined  wooden  tank  with  vertical  slots  for  accom- 
modating the  various  sizes  of  plates  will  be  found  very  con- 
venient. The  water  should  be  allowed  to  flow  in  at  the  bottom 
of  the  tank  and  overflow  should  be  at  the  top.  A  space  must 
be  left  between  the  bottom  of  the  tank  and  the  lower  edges 
of  the  plates,  to  allow  the  water  to  circulate  freely  between 
them.  For  the  same  reason  the  level  of  the  water  should 
extend  for  an  inch  or  more  above  the  top  edges  of  the  plates. 

In  the  dark  room  it  will  be  found  convenient  to  have  shelves 
for  the  various  chemicals,  a  good  balance  for  weighing  the 
chemicals,  a  hydrometer,  thermometer,  filter-paper,  mortar  and 
pestle,  glass  funnels,  and  such  appliances  as  will  suggest  them- 
selves to  every  one  who  has  had  to  do  with  chemicals. 

Rubber  Gloves. — Many  developers  stain  or  poison  the  hands 
and  skin,  and  it  is  therefore  a  good  idea  to  use  rubber  gloves 
during  the  development.  With  a  little  practice  one  becomes 
accustomed  to  these  rubber  gloves  and  they  are  not  incon- 
venient. Care  must  be  taken  to  wash  the  hands  or  rubber 
gloves  carefully  after  putting  a  plate  in  the  fixing  bath  and 
before  handling  another  plate  in  the  developer.  A  very  small 
amount  of  the  fixing  solution  will  interfere  seriously  with  the 
development. 

Printing. — The  printing  of  an  .r-ray  negative  does  not  differ 
essentially  from  that  of  an  ordinary  negative,  and  therefore 
it  needs  no  description  here.  It  is  a  matter  which  may  be 
safely  left  to  the  ordinary  photographer,  and  most  operators 
will  doubtless  prefer  to  do  this.  Moreover,  it  is  impossible 
to  get  in  a  print  all  of  the  detail  which  may  be  seen  in  an  x-ray 
negative,  and  in  the  majority  of  cases  the  negative  alone  suffices. 
If  the  printing  is  to  be  done  by  the  operator,  it  is  probable 
that  the  developing  papers  will  be  preferred  on  account  of  the 
smaller  amount  of  time  required  for  handling  them  and  the 


PRINTING.  205 

matter  of  being  independent  of  weather.  In  cases  in  which 
it  is  desired  to  have  a  print  at  the  earliest  possible  moment, 
it  may  be  made  from  the  wet  negative  in  the  following  manner. 
The  negative  is  placed  in  a  tray  of  water ;  a  sheet  of  printing  paper 
is  then  carefully  wet  and  placed  against  the  sensitive  film  under 
the  water.  The  plate  is  then  removed  with  the  paper  in  con- 
tact with  it  and  the  surface  of  the  glass  is  carefully  wiped  dry 
and  free  from  streaks.  The  print  may  then  be  made  with 
an  incandescent  lamp  or  gas-jet  in  the  usual  way.  For  such 
work  as  this,  developing  papers  like  Cyko,  Velox,  etc.,  are 
excellent.  The  glossy  papers  give  greater  detail  and  are  there- 
fore better  for  x-ray  negatives. 

Some  of  the  best  radiographic  prints  I  have  seen  have 
been  made  by  Dr.  E.  R.  Corson,  whose  method  is  described 
in  the  Annals  of  Surgery  for  October,  1901,  from  which  I  quote 
the  following: 

"One  of  the  disappointments  in  x-ray  work  is  the  great 
inferiority  of  the  print  compared  with  the  negative.  A  good 
sharp  negative,  with  much  of  the  bone  detail,  viewed  by  trans- 
mitted light,  seems  to  leave  nothing  to  be  desired,  and  yet, 
when  we  print  from  this  negative,  disappointment  is  sure  to 
follow.  What  is  the  main  cause  of  this?  It  is  because  of 
the  inequalities  of  the  negative,  an  inequality  which  does  not 
exist  to  anything  like  the  same  extent  in  the  ordinary  camera 
negative.  When  there  is  but  little  difference  in  the  thickness 
of  the  parts  skiagraphed,  this  inequality  is  slight;  but  if,  as 
is  usually  the  case,  the  thickness  of  the  bones  and  soft  parts 
varies  much,  the  inequality  in  the  negative  becomes  consider- 
able, and  is  the  disturbing  factor  in  the  printing,  the  thinner 
parts  of  the  bone  being  over-exposed  in  comparison  with  the 
thicker  parts.  You  have  a  negative  which  is  both  dense  and 
thin,  and  in  attempting  to  print  from  such  a  negative  the  denser 
portions  are  too  faint  or  do  not  appear  at  all,  and  the  thinner 
parts  are  too  dark,  and  in  both  cases  the  detail  suffers;  in  the 
first  instance  it  is  too  faint,  in  the  second  the  detail  is  smothered 
up  in  the  deep  shadows.  And,  really,  the  finer  your  negative 
is, — that  is,  the  more  detail  you  have, — the  more  does  this 
fault  show  up  in  the  print. 


206      PHOTOGRAPHIC  MATERIALS  AND  THEIR  MANIPULATION. 

"  For  some  time  I  have  been  trying  to  overcome  this  difficulty, 
and  generally  unsuccessfully.  My  usual  method  has  been  to 
use  a  shaded  ground-glass  screen,  or,  better  still,  the  passing 
of  the  hand  during  the  printing  over  the  thinner  parts  of  the 
negative  to  retard  the  printing  at  these  points.  This  was  the 
method  used  with  my  prints  of  the  epiphyses;  but  it  is  very 
uncertain,  very  irksome,  and  much  printing  paper  is  wasted. 

"In  some  recent  work  I  have  made  use  of  a  photographic 
trick  sometimes  used  by  professionals  in  portrait  work,  which 
seems  to  me  to  have  solved  the  problem.  It  consists  in  the 
following  manoeuver :  The  back  of  the  plate  having  been  cleaned 
of  all  spots  and  finger-marks,  it  is  evenly  and  carefully  flowed 
with  a  preparation  known  as  'Hance's  ground-glass  substitute, ' 
a  solution  of  certain  gum  resins  in  ether.  Great  care  must 
be  taken  to  prevent  the  solution  from  running  onto  the  film 
side,  otherwise  you  may  ruin  your  negative.  This  requires 
some  little  practice  to  do  properly.  I  have  found  that  if  you 
will  smear  the  edge  of  the  plate  with  vaselin,  you  are  less  liable 
to  meet  with  this  unfortunate  accident.  This  ether  solution, 
of  course,  evaporates  rapidly,  leaving  a  very  thin  coating  of 
gum  resin,  which  adheres  to  the  plate  with  great  tenacity, 
presenting  a  surface  difficult  to  distinguish  from  ground  glass. 
You  have  now  a  surface  into  which  you  can  rub  any  pigment 
and  which  will  stick.  With  an  artist's  stub,  such  as  is  used 
in  charcoal  work,  you  carefully  by  transmitted  light  rub  into 
the  thinner  parts  of  the  negative  burnt  umber  or  burnt  umber 
and  yellow  ocher.  If  properly  done,  you  do  not  rub  out  the 
faintest  hair-line  of  detail;  you  simply  even  up  your  negative. 
It  is  well,  before  this  process  is  undertaken,  to  take  an  ordinary 
print  from  the  unprepared  negative,  and  this  will  show  you  the 
inequalities  and  those  portions  which  require  the  pigment 
backing  to  retard  the  printing.  This  process  is  also  very 
valuable  when  you  wish  to  make  enlargements,  difficult  ordi- 
narily on  account  of  this  same  inequality.  In  this  instance 
you  can  make  a  very  even  positive  from  which  you  get  the 
enlarged  negative,  and  which  is  just  as  even  as  the  positive 
and  the  original  negative.  One  can,  of  course,  get  an  even 
negative  of  the  same  size  as  the  original  one  by  making  a  posi- 


PRINTING.  207 

tive,  and  from  this  making  a  negative  again,  thus  having  a 
plate  which  requires  no  backing,  and  which  can  be  preserved 
without  the  clanger  of  the  backing  rubbing  off,  as  in  the  first 
instance. 

"By  this  process,  then,  you  obtain  an  even  negative  without 
touching  the  film  side,  and  without  changing  in  the  slightest 
degree  its  detail.  It  admits  of  any  amount  of  careful  working 
up,  for  you  can  constantly  test  your  backing  by  a  print,  lighting 
it  here  and  making  it  denser  there,  until  the  print  comes  out 
with  all  the  detail  preserved,  and  with  the  greater  part  of 
the  beauty  of  the  negative  intact.  Of  course,  there  is  a  certain 
depth  of  film  on  the  negative  viewed  by  transmitted  light 
which  no  print  can  give,  but  the  real  essential  detail  is  there, 
just  as  in  any  ordinary  photographic  print." 

The  method  described  above  is  free  from  most  of  the  objec- 
tions that  can  be  brought  against  retouching  the  negative, 
because  what  is  done  is  really  to  so  control  the  light  that  each 
part  of  the  negative  shall  be  printed  to  best  advantage,  and 
there  is  little  or  no  risk  of  falsifying  the  record,  as  is  the  case 
when  the  negatives  are  retouched. 

Another  method  of  accomplishing  the  same  result  is  that  of 
using  what  is  known  among  photographers  as  the  brush  de- 
velopment. The  developer  is  applied  to  the  printing  paper 
by  a  fine  cameFs-hair  brush,  and  the  density  of  the  different 
parts  of  the  print  is  controlled  by  regulating  the  amount  of 
the  development  in  different  areas.  Success  in  this  manipula- 
tion requires  a  great  deal  of  skill.  The  method  advocated  by 
Dr.  Corson  is  certainly  much  easier,  and  has  the  advantage 
that  when  the  negative  is  once  prepared  any  number  of  prints 
may  be  made  from  it  without  further  trouble. 


CHAPTER  VIII. 
THE  CHOICE  OF  AN  X-RAY  OUTFIT. 

IN  the  preceding  pages  much  has  been  said  about  the  various 
appliances  that  make  up  the  x-ray  outfit,  and  about  those 
features  of  them  which  are  desirable  and  those  which  are  unde- 
sirable. In  regard  to  the  choice  of  auxiliary  appliances  it  is 
not  necessary  to  say  anything  further  than  to  advise  the  pur- 
chase of  those  of  the  best  quality  that  can  be  obtained.  The 
problem  of  choosing  an  outfit  then  resolves  itself  mainly  into  the 
question  of  what  type  of  exciting  apparatus  to  employ. 

The  choice  of  an  exciting  apparatus  will  depend  largely 
upon  the  class  of  work  which  it  is  intended  to  do,  and  upon 
the  character  of  the  available  source  of  electrical  energy. 

For  those  who  have  not  determined  just  what  use  they  will 
make  of  an  x-ray  outfit,  a  few  hints  as  to  what  they  may  reason- 
ably expect  to  do  with  it  may  be  helpful. 

Many  people  suppose  that  all  that  is  necessary  in  order 
to  do  any  sort  of  x-ray  work  is  to  buy  an  outfit  and  "  press 
the  button."  This  is  far  from  true,  but  any  one  with  a  reason- 
able amount  of  patience  and  skill,  and  with  proper  apparatus, 
may  make  satisfactory  fluoroscopic  examinations  of  the  ex- 
tremities and  of  the  thorax,  and  may,  with  a  little  more  trouble 
and  experience,  make  fair  radiographs  of  the  extremities  and 
thorax.  He  will  very  readih'  learn  to  operate  the  tubes  for 
the  therapeutic  application  of  the  x-ray.  Thorough  x-ray 
examinations  of  the  shoulder-joint,  the  abdominal  and  pelvic 
regions,  and  the  hip-joint  can  be  made  only  by  means  of  the 
radiograph.  Radiographs  of  these  parts  are  infinitely  more 
difficult  to  make  than  of  the  extremities  or  the  thorax.  It  is 
quite  probable  that  the  average  physician  will  not  want  to 
take  the  time  and  trouble  to  perfect  himself  in  the  art  of  radio- 
graphing the  difficult  parts  of  the  body.  In  justice  to  both 
himself  and  his  patient  it  will  be  better  to  have  this  sort  of 

208 


APPARATUS    FOR    IIO-VOLT    DIRECT    CURRENT.  209 

work  done  by  a  specialist  who  has  had  a  large  experience  and 
who  keeps  a  suitable  equipment  for  this  kind  of  work  always 
ready  for  use. 

The  prospective  purchaser  of  an  x-ray  equipment  will  be 
confronted  by  a  bewildering  diversity  in  kinds  of  apparatus 
offered  for  sale  and  conflicting  claims  as  to  which  type  of 
machine  and  which  make  of  any  particular  type  is  best.  Advice 
from  men  who  have  been  doing  x-ray  work  will  probably  be 
as  conflicting  as  that  from  the  dealers  who  have  apparatus 
to  sell.  The  man  who  has  been  successful  with  the  static 
machine  and  has  not  used  the  induction  coil  will  probably 
say  that  the  static  machine  is  far  superior  to  the  coil  for  every 
kind  of  x-ray  work.  There  are  hundreds  of  competent  workers 
who  say  that  the  induction  coil  is  the  only  proper  exciting 
apparatus  for  the  x-ray  tubes.  There  are  some  who  have  used 
the  high-frequency  apparatus  with  satisfaction  and  who  recom- 
mend it  strongly.* 

Successful  work  has  been  done  with  all  these  various  forms 
of  apparatus,  and  much  bad  work  has  also  been  done  with 
them.  Some  men  discard  the  static  machine  for  the  induc- 
tion coil  and  get  better  results,  others  discard  the  induction 
coil  for  the  static  machine,  with  a  like  improvement  in 
results. 

The  high-frequency  outfits  are,  for  reasons  which  have  been 
mentioned,  much  inferior  to  both  the  static  machine  and  the 
induction  coil  for  every  kind  of  x-ray  work.  They  are  not 
at  all  suitable  for  difficult  radiographic  work,  although  they 
may  be  used  for  the  easier  diagnostic  work  and  for  therapeutic 
purposes.  The  only  possible  reason  for  employing  the  high- 
frequency  outfit  is  that  it  can  be  readily  operated  from  the 
alternating  current  lighting  circuits.  However,  even  when  no 
other  source  of  energy  is  available,  the  two  other  types  of 
exciting  apparatus  will  be  preferable. 

Apparatus  for  no-Volt  Direct  Current. — If  a  110-volt  direct- 
current  lighting  circuit  is  available,  the  induction  coil  will 

*  X-ray  tubes  may  be  excited  by  other  means  than  by  the  use  of  the  three 
types  of  apparatus  above  mentioned,  but  these  three  are  the  only  ones  which 
have  had  any  extended  use. 
14 


210  THE    CHOICE    OF   AX    X-RAY    OUTFIT. 

undoubtedly  be  the  best  type  of  exciting  apparatus  to  em- 
ploy. 

For  the  man  who  expects  to  use  his  apparatus  occasionally 
for  fluoroscopic  examinations  or  easy  racliographic  work,  an 
induction  coil  rated  at  12-  or  15-inch  spark,  and  provided 
with  a  vibrating  interrupter  or  a  mercury  turbine  interrupter, 
will  probably  be  satisfactory.  Such  an  outfit  is  comparatively 
simple  in  operation,  and  is  not  very  liable  to  get  out  of  order. 

For  the  same  requirements  a  good  static  machine  will  answer 
perfectly  well,  and  may  be  preferred  by  those  who  wish  to 
employ  the  static  machine  for  other  purposes  than  j-ray  work. 
If  the  static  machine  is  preferred,  the  best  kind  to  get  will 
be  a  machine  having  eight  to  twelve  revolving  glass  plates 
about  30  inches  in  diameter.  With  the  static  machine  it  will 
be  necessary  to  get  a  small  direct-current  motor  with  a  speed- 
controlling  rheostat.  For  the  smaller  machine  a  one-sixth  horse- 
power motor  may  suffice,  but  it  will  usually  be  found  more 
satisfactory  to  use  a  motor  rated  at  about  one-fourth  horse- 
power. It  is  well  to  leave  the  selection  of  the  motor,  the 
pulleys,  and  the  rheostat  to  the  maker  or  dealer  from  whom 
the  static  machine  is  purchased,  but  when  doing  this,  a  few 
dollars  more  expended  for  a  motor  of  ample  power  will  not 
be  wasted. 

If  the  space  is  limited,  or  if  it  is  not  desired  to  use  electrical 
discharges  for  therapeutic  and  other  purposes  than  x-ray  work, 
it  will  be  better  to  use  an' induction  coil  outfit. 

For  the  man  who  intends  to  make  a  specialty  of  radiographic 
work  a  good  induction  coil  provided  with  interrupters  which 
produce  with  it  very  powerful  discharges,  is  indispensable. 
This  coil  may  be  rated  at  15-,  18-,  20-,  or  30-inch  spark  length. 
It  really  does  not  matter  much  about  the  spark  length  if  the 
energy  of  the  discharge  when  the  coil  is  delivering  sparks  about 
eight  inches  long  is  great  enough.  There  are  30-inch  coils 
which  are  unsuitable  for  the  most  difficult  radiographic  work, 
and  there  are  coils  rated  at  10-inch  spark  length  which,  equipped 
with  proper  interrupters,  will  deliver  more  energy  than  any 
x-ray  tube  yet  made  can  withstand  for  more  than  a  few  seconds. 
A  coil  giving  this  sort  of  a  discharge  is  the  one  to  be  used. 


FOR   ALTERNATING-CURRENT   CIRCUITS.  211 

It  should  be  supplied  with  at  least  two  interrupters:  an  electro- 
lytic interrupter  for  the  rapid  exposures  of  from  one  to  thirty 
seconds,  and  a  good  mechanical  interrupter  for  the  work  requir- 
ing continuous  operation.  For  this  kind  of  work  a  vibrating 
interrupter  may  be  used,  but  a  rotary  break  or  mercury  turbine 
interrupter  will  probably  be  found  more  satisfactory.  This 
induction  coil  and  interrupter  will  be  provided  with  a  rheostat 
of  large  carrying  capacity  for  controlling  the  strength  of  the 
current,  and  probably  with  an  ammeter  for  measuring  its 
strength,  perhaps  by  a  more  or  less  elaborate  switchboard 
with  the  controlling  devices  mounted  on  it. 

Many  of  the  successful  Rontgen  specialists  in  Germany 
employ  enormous  coils  which  are  designed  to  deliver  sparks 
one  meter  long.  In  the  chapter  on  induction  coil  I  have  given 
a  few  of  the  reasons  why  such  coils  are  not  only  unnecessary 
but  undesirable  for  x-ray  work.  These  statements  seem  justified 
by  the  fact  that  the  excellent  radiographs  and  the  exceedingly 
short  exposures  that  have  been  made  with  these  large  coils 
have  been  equalled,  if  not  surpassed,  by  the  use  of  an  induction 
coil  so  small  that  it  can  be  conveniently  carried  in  a  cab. 

For  the  large  hospital  or  public  institution  where  a  great 
amount  of  work  of  every  variety  is  to  be  done,  it  will  be  found 
advantageous  to  have  at  least  two  complete  x-ray  outfits,  and 
to  arrange  them  so  that  they  may  be  used  at  the  same  time 
for  therapeutic  purposes.  If  there  are  but  two  outfits,  it  will 
be  convenient  to  have  both  a  coil  and  a  static  machine.  If 
a  large  number  of  outfits  are  needed  for  treatment,  these  would 
better  be  induction  coils  of  about  8-  to  10-inch  spark  length, 
with  vibrating  or  mercury  interrupters. 

For  Alternating-current  Circuits. — When  the  only  available 
source  of  current  supply  is  an  alternating  electric  light  circuit, 
the  selection  of  an  equipment  will  be  somewhat  modified.  For 
ordinary  office  use  it  will  be  possible  to  employ  either  static 
machine  or  induction  coil  of  the  sizes  recommended  for  use 
with  the  direct  current. 

With  a  static  machine  it  makes  very  little  difference  whether 
the  power  is  derived  from  the  alternating,  or  direct-current 
circuit,  but  with  an  induction  coil  the  alternating  current  will 


212  THE    CHOICE    OF   AN   X-RAY    OUTFIT. 

not  give  results  so  satisfactory  as  may  be  obtained  with  the 
direct  current.  If  the  matter  of  space  is  not  to  be  considered, 
I  should  be  inclined  to  prefer  the  static  machine  for  these 
conditions.  An  alternating-current  motor  will  be  required 
instead  of  a  direct-current  motor,  and  since  nearly  all  alternat- 
ing-current motors  run  at  a  constant  speed,  a  speed-regulating 
rheostat  cannot  be  used,  and  it  will  be  necessary  to  regulate 
the  output  of  the  machine  by  varying  its  speed  independently 
of  the  motor.  This  may  be  accomplished  either  by  cone  pulleys 
giving  two  or  three  speeds,  or  by  the  friction  device  mentioned 
in  Chapter  IV.  There  is  really  not  much  necessity  for  accurate 
regulation  of  the  speed  of  the  static  machine,  and  I  think  that 
the  cone  pulleys  are  preferable.  They  are  simpler,  cheaper,  and 
less  likely  to  give  trouble. 

The  induction  coil  may  be  operated  from  an  alternating- 
current  circuit  in  several  ways  that  have  been  mentioned  in 
Chapter  III.  For  the  purpose  of  x-ray  treatments,  probably  the 
best  plan  is  to  use  a  mercury  turbine  interrupter  with  syn- 
chronous motor  shown  in  figure  33.  This  arrangement  will  also 
give  fairly  good  results  for  fluoroscopic  examinations  and  for 
radiographing  the  extremities.  It  can  be  operated  continuously 
without  trouble,  and  for  the  average  user  will  probably  give 
satisfactory  results.  For  the  purposes  of  x-ray  treatment  a  coil 
operated  by  the  liquid  interrupter  shown  in  figure  38  may  be 
used  with  double  focus  tubes.  This  arrangement  will  not  be 
so  satisfactory  for  fluoroscopic  examinations,  and  for  continuous 
operation  it  will  be  necessary  to  use  two  or  three  interrupters 
and  to  change  from  one  to  the  other  at  intervals  of  ten  to 
twenty  minutes. 

For  fluoroscopic  and  radiographic  work  the  best  method  of 
operating  an  induction  coil  directly  from  the  alternating  cur- 
rent will  be  to  use  the  Wehnelt  interrupter  and  single  focus 
tube.  Because  of  the  wearing  away  of  the  platinum  this  inter- 
rupter will  require  more  attention  than  the  liquid  interrupter 
mentioned  above,  and  for  continuous  operation  it  will  be  neces- 
sary, as  before,  to  use  more  than  one  interrupter. 

Various  electrolytic  valves  for  suppressing  one  wave  of  the 
alternating  current,  and  thus  allowing  the  current  to  flow  in 


WHEN  NO  LIGHTING  OR  POWER  CIRCUIT  IS  AVAILABLE.     213 

waves  of  one  direction  only,  have  been  devised.  It  has  been 
suggested  to  use  them  in  connection  with  ordinary  interrupters 
for  operating  induction  coils  from  alternating-current  circuit. 
These  devices  absorb  considerable  energy,  they  all  require  more 
or  less  attention,  and  they  deteriorate  rapidly. 

For  the  man  who  makes  a  specialty  of  radiographic  work 
and  who  has  only  the  alternating  current  source  of  supply 
available  the  best  plan  will  be  to  employ  a  powerful  induction 
coil  and  operate  it  with  a  Wehnelt  interrupter  of  the  type 
shown  in  figure  37.  In  his  work  the  exposures  will  be  short, 
and  the  wearing  away  of  the  platinum  will  not  be  of  so  much 
consequence  as  when  the  apparatus  is  used  for  treatments  in 
which  the  exposures  extend  over  ten  to  fifteen  minutes.  At 
present  there  is  no  method  of  operating  induction  coils  directly 
from  the  alternating-current  circuit  which  will  give  as  satis- 
factory results  in  radiographic  work  as  may  be  obtained  with 
the  direct  current.  However,  several  operators  have  obtained 
beautiful  radiographs  of  the  thorax  with  exposures  of  from 
twenty  to  sixty  seconds  by  using  the  arrangement  just  men- 
tioned. If  much  work  is  to  be  done  it  will,  of  course,  be  ad- 
visable to  have  several  electrolytic  interrupters.  For  continuous 
operation  of  the  coil  such  as  would  be  needed  in  making  fluoro- 
scopic  examinations,  the  mercury  turbine  interrupters  with 
synchronous  motor  will  be  very  useful. 

Hospital  equipments  for  use  with  the  alternating  current 
will  not  differ  materially  from  those  just  described. 

When  no  Lighting  or  Power  Circuit  is  Available. — When  this 
is  the  case,  the  static  machine  may  be  operated  by  hand-power, 
water-moter,  by  power  from  shafting,  by  a  gas-engine,  etc. 
Nearly  all  of  these  methods  will  be  found  more  or  less  incon- 
venient and  troublesome.  If  a  high  pressure  water-supply  is 
available,  a  water  motor  will  be  very  satisfactory  for  this 
purpose.  If  an  induction  coil  is  used,  it  may  be  operated 
either  from  primary  batteries  or  from  storage  batteries.  The 
best  plan  is  to  use  an  induction  coil  and  operate  it  from  a  storage 
battery.  If  there  is  a  power  station  near  by,  where  batteries 
may  be  recharged,  it  is  a  good  idea  to  have  two  sets  of  storage 


214  THE    CHOICE    OF   AN    X-RAY    OUTFIT. 

batteries,  so  that  one  may  be  used  while  the  other  is  being 
recharged. 

In  certain  isolated  cases  it  may  be  advisable  to  install  a  gas- 
engine  and  dynamo  for  operating  the  coil,  but  this  is  a  matter 
which  should  be  left  to  a  competent  electrical  engineer.  Such 
outfits  are  of  standard  manufacture  for  isolated  electric  lighting 
plants.  They  are  rather  expensive,  and  gas-  or  oil-engines 
are  more  or  less  troublesome. 

Excellent  radiographs  of  every  part  of  the  body  may  be 
obtained  by  employing  a  coil  operated  from  a  storage  battery, 
but  it  will  be  necessary  to  make  longer  exposures  than  would 
be  needed  when  the  coil  is  operated  from  an  electric  lighting 
or  power  circuit.  For  use  with  a  storage  battery  it  is  advisable 
to  have  a  coil  somewhat  larger  than  would  be  necessary  for 
use  with  the  electric  lighting  circuit.  A  vibrating  interrupter 
or  a  mercury  dip  interrupter  will  be  best  for  use  with  the  storage 
battery. 

Selection  of  Tubes. — For  the  use  with  static  machines,  tubes 
of  the  type  shown  in  figures  7,  8,  and  9  will  be  found  most 
satisfactory  and  reliable.  They  are  cheaper  than  the  more 
complicated  forms  with  regulators,  and  with  a  static  machine 
it  is  better  to  have  a  large  number  of  these  tubes  of  different 
degrees  of  exhaustion  than  to  attempt  to  secure  different  de- 
grees of  penetration  from  the  same  tube  by  means  of  a  vacuum 
regulator. 

For  treatment,  for  fluoroscopic  work,  and  for  the  easier 
radiographic  work,  tubes  of  the  same  types  will  be  found  very 
satisfactory  for  use  with  the  induction  coil. 

For  the  most  rapid  radiographic  work  with  the  induction 
coil  and  electrolytic  interrupter,  it  will  be  necessary  to  use 
tubes  with  strong,  well-made  targets  which  enable  them  to 
withstand  heavy  discharges.  Tubes  with  very  heavy  platinum 
targets  faced  with  iridium  are  probably  as  good  as  any,  but 
they  are  expensive  and  difficult  to  obtain,  and,  moreover,  it 
is  quite  difficult  to  regulate  the  vacuum  of  such  a  tube. 

Of  the  types  on  the  market,  the  water-cooled  tubes,  such 
as  the  one  shown  in  figure  17,  and  the  heavy  target  tubes, 
such  as  are  shown  in  figures  12,  13,  14,  and  18,  are  probably  the 


ACCESSORY  APPLIANCES.  215 

best  for  this  purpose.  For  use  with  induction  coils,  regulating 
tubes  are  generally  preferred  to  the  non-regulating  tubes, 
except  when  comparatively  weak  discharges  are  employed,  such 
as  are  used  in  x-ray  treatment.  The  addition  of  the  regulator 
increases  the  useful  life  of  the  tube,  and  although  none  of  them 
are  entirely  satisfactory,  they  do  give  some  control  of  the 
vacuum. 

Accessory  Appliances. — While  the  exciting  apparatus  and 
tubes  are  the  most  essential  parts  of  an  x-ray  equipment,  they 
form  but  a  small  part  of  it.  A  number  of  auxiliary  devices, 
such  as  tube-holders,  plate-holders,  fluoroscopes,  numbering 
devices,  localizing  apparatus,  etc.,  will  be  needed.  The  choice 
of  these  will  be  determined  by  the  character  of  the  work  which 
one  intends  to  do. 

The  merits  of  these  accessories  have  been  discussed  in  the 
chapters  on  Fluoroscopy  and  Radiography. 


PART   II 

THE  THERAPEUTIC  APPLICATION 
OF  X-RAYS. 

BY 

WILLIAM  ALLEN   PUSEY,  M.  D. 


PREFACE. 


DURING  the  last  three  years  an  extensive  literature  has  sprung 
up  upon  the  subject  of  the  therapeutic  application  of  x-rays, 
and  the  present  seems  an  opportune  time  to  make  a  critical 
review  of  this  literature.  I  have  undertaken  in  the  following 
pages  to  consider  as  carefully  as  I  am  able  the  authentic  litera- 
ture which  has  developed  upon  this  subject,  and  I  have  supple- 
mented that  by  as  full  a  review  of  my  own  experience  in  this 
field  as  the  subject  seemed  to  warrant.  I  have  given  as  fully 
as  possible  the  details  of  my  own  experience  and  of  the  experi- 
ence of  other  workers,  for  it  is  only  by  the  accumulation  of  such 
data  that  it  becomes  possible  to  arrive  at  a  satisfactory  estimate 
of  the  value  of  the  method. 

The  aim  has  been  particularly  to  elucidate  fully  the  practical 
aspects  of  the  subject,  so  that  the  reader  can  get  definite  infor- 
mation upon  the  various  practical  points  that  go  to  make  up 
a  satisfactory  working  knowledge  of  the  subject. 

The  subject  of  x-ray  therapeutics  is  of  course  in  a  stage  of 
development;  it  is  in  a  comparatively  early  stage  of  develop- 
ment, but  data  are  not  lacking  even  at  the  present  time  to  allow 
us  to  obtain  a  not  unsatisfactory  grasp  of  the  limitations  and 
possibilities  of  the  method.  In  order  to  arrive  at  satisfactory 
conclusions  upon  these  questions,  what  we  must  have  is  facts; 
and  the  aim  in  these  pages  has  been  to  record  the  facts.  That 
done,  the  reader  is  in  position  to  attach  to  them  the  weight 
to  which  in  his  opinion  they  are  entitled.  The  only  claim  that 
I  would  make  is  that  it  has  been  my  constant  endeavor  to  keep 
well  within  the  facts. 

WM.  ALLEN  PUSEY. 

Chicago,  April,  1903. 


219 


CHAPTER  I. 
THE  EFFECTS  OF  X-RAYS  ON  TISSUES. 

THE  use  of  x-rays  for  therapeutic  purposes  presents  a  problem 
entirely  different  from  that  which  confronts  us  in  the  use  of 
the  same  agent  as  a  means  of  diagnosis.  On  the  one  hand, 
the  ideal  condition  is  to  get  a  satisfactory  image  without  in 
any  way  affecting  the  tissues;  on  the  other,  we  are  directly 
and  solely  concerned  with  the  effect  upon  living  tissues.  In 
the  use  of  x-rays  for  therapeutic  purposes  we  must  utilize 
those  very  qualities  of  the  agent  which  we  strive  to  escape  in 
diagnostic  work;  we  must  produce  effects  upon  the  tissues, 
and  we  must  so  regulate  these  effects  that  they  may  be  utilized 
without  overstepping  the  bounds  of  safety.  It  goes  without 
saying  that  the  utilization  of  the  effect  of  x-rays  on  tissues 
presents  a  nice  problem  in  the  regulation  of  an  agent  whose 
control  is  extremely  difficult,  and  that  for  any  successful  solution 
of  this  problem  as  complete  a  knowledge  as  possible  of  the 
effect  of  x-rays  upon  living  tissues  is  of  fundamental  impor- 
tance. As  a  preliminary,  therefore,  to  the  application  of  x-rays 
to  therapeutic  purposes  we  must  consider  fully  their  effects 
upon  living  tissues.  Fortunately  our  knowledge  upon  this 
subject,  thanks  to  the  studies  of  numerous  observers,  is  by 
no  means  so  limited  as  is  generally  supposed. 

Gross  Effects  upon  Tissues. — The  effects  of  x-rays  upon 
tissues  have  been  studied  almost  exclusively  as  they  occur 
in  the  skin,  for  the  very  obvious  reason  that  the  skin,  which 
bears  the  brunt  of  the  exposures,  is  the  part  which  always 
shows  the  most  marked  x-ray  effects.  When  the  surface  of 
the  body  is  exposed  to  x-rays  to  a  sufficient  extent  to  produce 
a  reaction,*  very  definite  results  occur.  The  first  effect  to  be 

*  Various  names  have  been  used  to  describe  the  reaction  produced  in  tissues 
by  or-rays.  The  term  burn  was  first  applied,  but  vigorous  objections  have  been 
raised  against  its  use,  chiefly  on  the  ground  that  the  injury  produced  by  x-rays 

221 


222  THE    EFFECTS    OF   X-RAYS   OX    TISSUES. 

seen  is  either  slight  pigmentation,  slight  erythema,  blanching 
of  the  hairs,  or  loosening  of  the  hairs.  These "  changes  usually 
develop  in  the  above  order,  but  any  one  of  them  may  come 
first.  Pigmentation  may  occur  without  redness;  again,  the 
pigmentation  may  be  very  slight,  or  not  occur,  or  be  completely 
overshadowed  by  the  redness.  Loosening  of  the  hairs  frequently 
occurs  without  blanching,  but  I  have  not  seen  the  reverse 
happen.  Neither  of  these  latter  changes  occurs  without  accom- 
panying pigmentation  or  erythema. 

Pigmentation. — The  effect  that  shows  itself  first  in  perhaps 
most  cases  is  pigmentation.  This  is  likely  to  be  quickly  fol- 
lowed by  blanching  or  loosening  of  the  hairs,  particularly 
dark  hairs,  and  then  by  the  development  of  redness.  This 
pigmentation  of  the  skin  from  moderate  x-ray  influence  differs 
in  no  apparent  respect  from  that  produced  by  exposures  to 
sunlight.  It  is  a  superficial  deposit  of  pigment,  and  is  un- 
questionably, in  my  opinion,  a  result  of  the  same  process  that 
causes  tanning  from  exposure  to  sunlight.  The  amount  of  this 
deposit  of  pigment  varies  considerably  according  to  the  sus- 
ceptibility of  the  individual  and  the  intensity  of  the  x-ray 
exposure.  In  many  cases  it  amounts  only  to  a  slight  tanning; 
in  certain  others  after  long-continued  exposure  the  skin  becomes 
a  dark  brown.  At  times  on  surfaces  exposed  to  moderate 
x-ray  influence  there  develop  freckles  indistinguishable  from 
the  ordinary  lentigines  produced  by  sunlight.  This  freckling 
is  sometimes  a  precursor  by  several  days  of  diffuse  pigmenta- 
tion, but  such  diffuse  pigmentation  is  by  no  means  usually 
associated  with  any  preliminary  appearance  of  freckles.  The 

does  not  entirely  correspond  to  a  heat  burn.  To  my  mind  the  objection  is  not 
particularly  valid.  Burn  is  by  no  means  confined  in  its  application  to  the  re- 
action produced  by  heat.  It  is  applied  to  injuries  produced  by  sunlight  and 
other  forms  of  light,  by  electricity,  and  by  chemicals,  all  of  which  have  pecu- 
liarities. It  is,  of  course,  true  that  the  injuries  produced  by  arrays  are  not 
identical  with  those  produced  by  heat,  but  they  are  processes  which  suggest 
very  closely  heat  burns  and  other  injuries  to  which  the  term  burn  is  applied. 
As  a  matter  of  fact,  burn  describes  the  condition  more  closely  than  any  other 
term  that  we  have.  And  as  burn  has  long  since  ceased  to  be  confined  in  its 
application  to  heat  burns,  but  is  applied  to  various  similar  processes  without 
predicating  anything  as  to  their  causation,  it  seems  an  excess  of  purism  to  deny 
the  use  of  the  word  to  the  injuries  produced  by  x-rays. 


DERMATITIS.  223 

appearance  of  freckles  occurs  in  individuals  who  show  the 
same  phenomenon  under  exposure  to  sunlight.  Ordinarily  the 
individual  who  shows  the  greatest  amount  of  pigmentation 
from  x-ray  exposure  is  the  one  who  normally  has  a  large  amount 
of  pigment  in  the  skin.  The  reaction  of  different  individuals 
in  respect  to  the  deposit  of  pigment  is  very  similar  to  their 
reaction  to  sunlight.  Skins  which  burn  rather  than  tan  under 
sunlight  develop  erythema  rather  than  pigmentation  under 
x-rays,  and  skins  which  tan  without  burning  under  sunlight 
show  relatively  the  same  reaction  under  x-rays.  Indeed  the 
entire  reaction  produced  by  x-ray  irritation,  whether  tanning 
or  burning,  is  practically  identical  with  that  produced  by 
sunlight. 

Dermatitis. — The  inflammatory  effects  produced  by  x-rays 
upon  tissues  may  be  divided  into  four  classes,  corresponding 
to  the  four  degrees  of  heat  burns  ordinarily  described.  In 
burns  of  the  first  degree  there  is  a  dry  dermatitis  with  erythema 
without  destruction  of  tissue;  in  burns  of  the  second  degree, 
dermatitis  with  the  formation  of  vesicles  and  blebs  but  without 
deeper  involvement;  in  burns  of  the  third  degree,  destruction 
of  the  epidermis;  in  burns  of  the  fourth  degree  the  destruction 
involves  not  only  the  entire  epidermis,  but  the  corium  as  well, 
and  also  the  underlying  tissue  to  a  greater  or  less  extent.  The 
dermatitis  produced  by  x-rays  appears  first  around  the  follicles 
as  punctate  redness,  which  immediately  develops  into  a  diffuse 
pinkish  erythema  over  the  involved  area.  This  is  likely  to 
be  accompanied  by  some  tingling  or  burning.  The  process 
may  stop  at  this  point.  If  so,  prompt  subsidence  of  irrita- 
tion usually  occurs,  accompanied  by  slight  desquamation,  after 
which  there  is  left  more  or  less  pigmentation,  depending 
upon  the  pigment-forming  characteristics  of  the  particular 
skin.  If  the  process  goes  beyond  this  first  erythema,  there 
may  develop  a  lively  red  dermatitis  which  is  at  first  dry  but 
is  likely  to  go  on  to  vesiculation.  The  process  may  stop  at 
vesiculation ;  if  so,  the  vesicles  rupture  and  there  is  left  a 
slightly  weeping  surface  which  is  usually  rapidly  covered  by 
a  layer  of  grayish  horny  epithelium,  and  the  process  undergoes 
prompt  involution  from  this  point.  The  subjective  sensations 


224  THE   EFFECTS    OF   X-RAYS   OX   TISSUES. 

accompanying  this  type  of  burn  do  not  differ  materially  from 
those  of  a  similar  degree  of  dermatitis  from  other  causes. 

If  the  x-ray  irritation  goes  beyond  the  stage  just  described, 
instead  of  stopping  at  the  development  of  a  lively  red  dermatitis 
with  vesiculation,  the  surface  becomes  a  dark  angry  red.  The 
congestion  in  this  condition  is  intense;  the  redness  disappears 
on  pressure  but  instantly  returns ;  vesicles  and  bulla?  form  upon 
the  surface,  rupture,  and  leave  a  congested,  weeping  surface. 
There  then  develops  upon  this  raw  surface  a  thin  yellowish-gray 
necrotic  membrane.  This  is  closely  adherent  and  its  forcible 
removal  is  followed  by  very  free  bleeding.  This  necrotic  mem- 
brane is  made  up  solely  of  epithelium.  One  is  apt  to  believe 
that  it  involves  the  connective  tissue,  but  in  the  particular  degree 
of  x-ray  burn  now  under  consideration  this  is  not  the  case.  With 
burns  of  this  degree  there  is  likely  to  be  considerable  swelling 
of  the  connective  tissue.  The  accompanying  subjective  sensa- 
tions vary  very  much  hi  individuals;  some  patients  complain 
very  little  or  not  at  all,  but  in  most  of  them  there  is  very  decided 
burning  or  itching.  In  some  cases  the  itching  is  very  intense 
and  persists  for  a  comparatively  long  time.  Some  patients  com- 
plain of  pain,  but  the  pain  is  never  of  the  severe  character 
found  in  x-ray  burns  with  destruction  of  connective  tissue. 

The  course  of  burns  which  reach  this  point  of  irritation  varies. 
Some  of  them  recover  rapidly ;  the  necrotic  membrane  is  promptly 
thrown  off,  horny  epidermis  grows  rapidly  around  the  borders, 
islands  of  horny  epidermis  spring  up  at  various  points 
in  the  affected  area,  and  in  the  course  of  three  or  four  weeks 
from  the  time  of  the  appearance  of  the  bulke  the  area  is  again 
covered  with  horn}'  epidermis.  Other  cases  do  not  recover  so 
rapidly.  The  formation  of  epidermis  is  slower,  and  at  times 
the  recovery  will  be  retarded  by  vesicles  and  bulla?  reappearing, 
perhaps  again  and  again,  after  a  new  layer  of  horny  epidermis 
has  formed.  In  such  a  case,  when  relapses  occur,  the  surface  is 
more  or  less  covered  with  grayish  horny  epidermis,  interspersed 
with  many  weeping  patches.  With  these  relapses  the  irritation 
may  be  continued  for  several  months,  but  usually  in  the  course 
of  three  or  four  months  relapses  cease,  and  the  surface  becomes 
covered  with  permanent  horny  epidermis.  Redness  may  persist 


BURNS   INVOLVING   THE    SUBCUTANEOUS   TISSUE.  225 

for  many  weeks,  but  there  is,  as  a  rule,  not  much  pigmentation. 
The  epithelium  formed  over  the  surface  is  smooth  and  thin, 
and  the  entire  absence  of  hair  and  follicles  gives  the  skin  a 
smooth  but  not  disfiguring  appearance.  This  new  skin  is  for 
some  time  quite  sensitive  to  external  irritants.  Finally,  how- 
ever, the  usual  tolerance  develops. 

After-effects  on  the  Skin. — After  x-ray  irritation  of  all  of 
the  degrees  above  described,  the  skin  presents  a  slightly  atrophic 
appearance.  It  is  softer  and  a  little  thinner  than  normal  and 
is  liable  to  show  a  slight  cigarette-paper  appearance  with 
exaggeration  of  the  normal  lines.  If  the  exposures  have  been 
over  the  face,  the  wrinkling  of  the  skin  at  the  corners  of  the 
mouth  may  be  sufficient  to  attract  the  patient's  attention. 
This  atrophy  of  the  skin  is  most  pronounced  immediately  after 
the  disappearance  of  the  redness,  and  gradually  disappears 
in  most  cases.  These  atrophic  changes  are  seen  at  times  in 
cases  in  which  the  dermatitis  has  been  almost  nil,  but  in  which 
there  has  been  a  continued  moderate  x-ray  effect  sufficient 
to  cause  pigmentation  and  destruction  of  the  follicles. 

Burns  Involving  the  Subcutaneous  Tissue. — In  burns  of  the 
fourth  degree  the  evolution  up  to  the  point  of  congestion  and 
vesiculation  is  the  same  as  that  described  above  for  burns  of 
lesser  severity,  but  the  process  does  not  stop  at  that  point. 
The  congestion  goes  on  until  the  surface  is  almost  cyanotic, 
the  skin  becomes  brawny  and  tense,  bullre  develop,  and  these 
are  followed  by  necrosis  of  the  underlying  tissue  (Fig.  92).  The 
resulting  lesion  is  practically  unique.  There  develops  a  hard, 
leathery,  dark-grayish  mass  of  mummified  tissue,  which  is 
closely  adherent  and  is  surrounded  by  an  indurated,  inflamed 
periphery.  Its  dry,  mummified  appearance,  its  leathery  con- 
sistency, and  its  "almost  malignant  tendency  to  persist," 
place  it  in  marked  contrast  with  any  other  similar  lesion.  The 
line  of  demarcation  between  the  living  and  dead  tissue  of  these 
lesions  is  not  well  established.  Butler  *  has  observed  that 
occasionally  tissue  that  is  black  and  apparently  dead,  when 
cut  bleeds  and  causes  great  pain;  and  Cassidy  f  in  the  excision 

*  American  Practitioner  and  News,  1900,  xxix,  p.  361. 
t  Medical  Record,  1900,  Ivii,  p.  180. 
15 


226  THE    EFFECTS   OF  X-RAYS   ON   TISSUES. 

of  such  a  slough  found  that  to  get  all  of  the  diseased  tissue 
he  had  to  carry  his  incision  two  inches  outside  of  what  appeared 
on  the  surface  to  be  the  line  of  demarcation.  These  masses 
of  apparently  dead  tissue,  if  they  are  not  removed  by  surgical 
means,  are  likely  to  persist  for  a  long  time.  Usually  they  are 
not  thrown  off  for  several  months,  and  their  persistence  may 
extend  to  a  year  or  more.  The  surrounding  tissues,  however, 
in  time  begin  to  regain  their  tone,  the  borders  of  the  ulcers 
gradually  contract  and  the  necrotic  mass  disappears,  and 
finally  scar  tissue  takes  its  place. 

Extent  of  Burns.  Pain.  Scars. — The  depth  to  which  the 
tissues  are  involved  in  burns  of  this  degree  is  limited  only  by 
the  intensity  of  the  x-ray  effects.  In  Cassidy's  case  the  injury 
involved  the  tissues  of  the  thigh  to  the  depth  of  an  inch  and 
a  half,  surrounding  but  not  affecting  the  femoral  artery.  In 
a  case  for  a  description  of  which  I  am  indebted  to  Dr.  E.  Wyllys 
Andrews,  the  burn  "  included  the  whole  external  ear,  the  right 
eyelids  and  eyeball,  and  the  outer  table  of  the  skull,  in  the 
parietal  region."  The  superficial  extent  is  limited  only  by  the 
extent  of  the  exposure.  In  a  case  seen  by  Dr.  L.  L.  McArthur 
' '  the  burn  began  at  chin  and  ended  at  symphysis,  and  extended 

from  right  axillary  line  to  left  mammary 

The  gangrenous  area  was  about  nine  inches  long  by  six  wide 
when  I  operated  some  three  months,  I  think,  after  the  exposure." 

The  pain  accompanying  these  lesions  is  of  the  most  varying 
intensity.  Rarely  it  is  not  severe.  In  the  great  majority  of 
cases  it  is  extreme.  It  is  described  at  times  as  dull  boring 
pain,  again  as  sharp  lancinating  pain,  again  as  burning,  "as 
if  red-hot  coals  were  applied  to  the  part."  The  scars  left 
after  these  ulcers  are  similar  to  the  scars  after  other  ulcers 
of  the  same  extent,  with  the  exception  that  they  are  apt  to 
be  more  vascular.  Sequeira  *  has  reported  a  case  in  which 
there  remained  in  the  scar  numerous  telangiectases,  and  AVylie  f 
has  reported  a  case,  probably  of  similar  character,  in  which 
there  persisted  three  months  after  the  healing  of  the  ulcer 
scarlet  rings  the  size  of  a  half-dollar,  apparently  permanent. 

*Brit.  Jour,  of  Derm.,  1902,  xiv,  p.  19. 
fBrit.  Med.  Jour.,  1901,  i,  p.  338. 


227 


CHRONIC   X-RAY   DERMATITIS — HYPERKERATOSIS.  229 

Chronic  X-ray  Dermatitis. — There  is  a  fifth  form  of  x-ray 
injury  which  is  seen  in  x-ray  workers  who  are  exposed  more 
or  less  to  the  influence  of  the  rays  over  a  long  period  of  time. 
It  occurs  almost  exclusively  on  the  hands,  by  reason  of  their 
greater  exposure,  and  presents  itself  as  a  persistent  atrophic 
dermatitis.  The  skin  of  the  affected  areas,  usually  the  backs 
of  the  hands,  becomes  atrophic  and  thin,  and  crackled  like 
parchment.  It  may  be  smooth  and  glassy  in  appearance,  with 
entire  absence  of  the  follicular  openings  and  hairs,  and  with 
a  tendency  to  crack  about  the  joints.  The  skin  is  pinkish- 
white,  mottled  with  small  reddish  vascular  patches,  and  with 
decided  redness  about  the  knuckles.  Codman  *  describes  this 
condition  as  follows:  "In  the  less  pronounced  forms  the  skin 
appears  chapped  and  roughened,  and  the  normal  markings  are 
destroyed;  at  the  knuckles  the  folds  of  skin  are  swollen  and 
stiff,  while  between  there  is  a  peculiar  dotting  resembling 
small  capillary  hemorrhages.  The  nutrition  of  the  nails  is 
affected  so  that  the  longitudinal  striations  become  marked 
and  the  substance  becomes  brittle.  If  the  process  is  more 
severe,  there  is  a  formation  of  blebs,  exfoliation  of  epidermis, 
and  loss  of  the  nails.  In  the  worst  form  the  skin  is  entirely 
destroyed  in  places,  the  nails  do  not  reappear  and  the  tendons 
and  joints  are  damaged." 

Hyperkeratosis. — While  the  condition  in  these  chronic  forms 
of  x-ray  irritation  is  as  a  whole  atrophic,  there  is  at  times  a 
peculiar  tendency  to  hyperkeratosis  which  shows  itself  in  in- 
creased horniness  of  the  epidermis  about  the  knuckles  and 
in  the  formation  of  keratotic  patches.  In  some  cases  this 
is  very  marked,  so  that  the  affected  parts,  usually  the  backs 
of  the  hands,  have  scattered  over  them  many  keratoses  with 
or  without  inflamed  bases.  The  appearance  is  very  similar 
to  that  seen  in  cases  of  senile  keratosis  where  the  patches 
are  inflamed  and  have  a  tendency  to  epitheliomatous  degenera- 
tion. In  one  case  that  I  have  seen,  in  which  the  face,  the 
arms,  the  hands,  and  the  front  and  back  of  the  chest  were 
involved  in  a  chronic  x-ray  dermatitis,  the  atrophic  dry  skin, 
the  very  deep  freckling,  the  numerous  hyperkeratoses.  and 

*Phila.  Med.  Jour.,  1902,  ix,  438. 


230  THE    EFFECTS   OF   X-RAYS   ON    TISSUES. 

the  telangiectases  made  a  picture  strikingly  like  that  of  an 
early  stage  of  xeroderma  pigmentosum.  Indeed  in  some  of 
the  cases  this  resemblance  to  senile  keratosis  with  a  predisposi- 
tion to  epitheliomatous  degeneration  has  been  so  marked  that 
I  believe  there  is  a  possibility  of  epitheliomata  developing 
on  these  bases. 

The  above  was  written  before  I  knew  of  any  other  observation 
upon  this  point.  Johnston,*  however,  has  called  attention  to 
this  keratosis  as  ' ' precancerous  keratosis."  He  believes  that 
these  patches  are  likely  to  become  epitheliomata,  and  gives  a 
report  of  the  case  of  a  surgeon  who  used  x-rays  extensively, 
on  the  backs  of  whose  hands  about  twenty  keratoses  developed. 
Two  of  the  largest  were  excised  and  examined  microscopically, 
the  first  showing  only  subacute  inflammation  in  the  cutis, 
with  lymphocytosis  and  some  proliferated  fibroblasts.  The 
second,  however,  in  his  opinion  showed  unmistakable  evidences 
of  malignancy  in  the  form  of  numerous  mitoses  and  rupture 
of  epithelium  into  the  corium.  In  an  as  yet  unpublished  dis- 
cussion before  the  American  Dermatological  Association,  Bos- 
ton, September,  1902,  Dr.  C.  W.  Allen  reported  a  case  of  epithe- 
lioma which  developed  in  the  cicatrix  of  an  x-ray  burn  on 
the  back  of  the  wrist,  and  for  which  amputation  of  the  fore- 
arm was  done,  and  Dr.  J.  C.  White  referred  to  an  epithelioma 
which  had  developed  in  an  x-ray  burn.  This  condition  of 
h}^perkeratosis  from  chronic  x-ray  irritation  is  therefore  one 
of  serious  importance,  and  its  dangerous  possibilities  should  be 
borne  in  mind.  It  is  probable  in  my  opinion  that  many  cases 
of  epithelioma  will  be  found  to  develop  upon  the  backs  of  the 
hands  of  x-ray  workers  who  have  a  persistent,  chronic  inflam- 
matory process  with  hyperkeratosis,  as  a  result  of  continued 
exposures  to  x-rays. 

Changes  in  the  Appendages. — The  reference  to  the  nails  in 
the  quotation  from  Codman  above  describes  very  well  the 
changes  which  occur  in  the  nails  in  all  types  of  x-ray  burns. 
Evidences  of  marked  nutritional  disturbances  in  the  nails  appear 
early,  for  the  nails,  like  the  other  appendages  of  the  skin,  show 
a  marked  susceptibility  to  the  influence  of  x-rays.  The  changes 

*  Phila.  Med.  Jour.,  1902,  ix,  p.  220. 


DEEP-SEATED    X-RAY    EFFECTS.  231 

in  the  nails  vary  from  slight  linear  striation  to  the  production 
of  a  mere  rudimentary  nail,  or  the  absence  of  the  nails  entirely. 
The  changes  in  the  other  appendages  have  been  already  briefly 
referred  to  above.  In  all  degrees  of  x-ray  irritation  the  hairs 
are  affected.  Outfall  of  the  hairs  occurs  with  or  without 
previous  blanching.  In  severe  x-ray  burns  the  burn  usually 
develops  before  the  hairs  fall  out.  When  the  surface  has 
become  brawny  and  cyanotic,  the  hairs  may  still  remain,  but 
they  come  out  without  force,  as  after  a  scald. 

Deep-seated  X-ray  Effects. — Several  cases  have  been  reported 
of  internal  lesion  due  to  x-rays  without  corresponding  effect 
upon  the  overlying  tissue.  N.  Stone  Scott,*  in  a  review  of 
x-ray  injuries,  has  considered  all  these  cases.  Among  the  cases 
of  x-ray  injuries  that  he  was  able  to  find  there  were  but  six 
which  could  possibly  be  classed  as  primary  internal  injuries, 
and  in  none  of  these  is  the  evidence  conclusive.  The  case  to 
which  the  greatest  attention  has  been  given  is  Gilchrist's  f  case 
of  x-ray  dermatitis  of  the  hand  with  supposed  osteoplastic 
periostitis  of  the  bones  of  the  hand.  Scott  considers  this  case 
at  length,  and  concludes,  correctly  in  my  opinion,  that  the 
periosteal  lesion  is  not  demonstrated,  and  that  Gilchrist's  con- 
clusion that  there  was  a  thickening  of  the  bones  of  the  hand 
is  an  incorrect  interpretation  of  the  pictures.  It  is,  I  believe, 
a  priori  highly  improbable  that  primary  deep-seated  x-ray 
effects  can  be  produced  upon  normal  tissue  without  more 
intense  effect  being  produced  in  the  overlying  tissue,  and  there 
are  no  cases  on  record  that  tend  to  weaken  this  theoretical 
position. 

This  is  an  entirely  different  matter  from  the  statement  that 
effects  are  not  produced  upon  deeper  tissues.  There  is  every 
reason  to  believe  that  x-rays  may  affect  deep-seated  tissue, 
but  this  effect  must  be  less  than  that  upon  the  tissues  nearer 
the  source  of  the  x-rays.  Every  theoretical  consideration  indi- 
cates that  the  effect  of  x-rays  on  the  deep  tissues  is  relatively 
less  than  upon  the  overlying  tissues.  The  x-rays  of  course 
penetrate  the  deeper  tissues,  even  to  the  point  of  going  entirely 

*  Transactions  Ohio  Medical  Society,  1897,  lii,  p.  139. 
t  Johns  Hopkins  Hosp.  Bull.,  1897,  viii,  p.  17. 


232  THE    EFFECTS   OF   X-RAYS    ON    TISSUES. 

through  the  body,  and  certain  of  the  rays  are  absorbed  by 
every  tissue  through  which  they  pass. 

In  cases  which  I  have  had  under  treatment  for  various 
pathological  conditions  the  results  leave  no  room  for  doubt 
that  x-rays  produced  definite  effects  upon  deep-seated  tissues. 
In  a  case  of  recurrent  carcinoma  of  the  breast  with  involvement 
of  the  axilla,  and  enormous  oedema  of  the  arm  (Case  75),  not 
only  all  evidence  of  carcinoma  disappeared,  but  also  very 
great  oedema.  In  a  second  case  of  carcinoma  of  the  breast 
(Case  97)  the  findings  are  even  more  definite.  This  was  a 
case  of  primary  carcinoma  of  the  breast  with  involvement  of 
the  axilla  and  with  metastases  in  the  spine  and  in  the  chest, 
when  treatment  was  begun.  The  exposures  were  given  only 
over  the  breast  and  axilla.  The  patient  died  three  months 
after  the  beginning  of  treatment.  In  the  mean  time  an  acute 
dermatitis  had  been  produced  on  at  least  two  occasions.  At 
the  postmortem,  held  by  Dr.  J.  J.  Larkin,  of  Chicago,  it  was 
found  that  "  the  tumor  of  the  breast  had  nearly  all  disappeared" 
and  "the  enlarged  glands  under  the  arm  on  affected  side  had 
reduced  to  one-third  of  their  former  size."  Similar  deep-seated 
effects  of  the  rays  are  to  be  seen  in  a  case  of  sarcoma  (Case 
128),  and  in  Case  149,  of  pseudo-leukemia.  In  all  of  these 
cases  the  lesions  reached  nearly  to  the  surface,  but  the}7  extended 
certainly  to  a  depth  of  several  inches,  and  the  results  leave 
no  room  for  doubt  that  the  deepest  tissue  was  affected  as  well 
as  that  nearer  the  surface. 

Rollins  *  has  performed  experiments  upon  guinea-pigs  which 
are  interesting  in  this  connection.  He  exposed  two  strong 
guinea-pigs  two  hours  a  day  to  x-rays.  One  died  in  eleven 
days,  the  other  in  eight  days.  In  a  pregnant  female  guinea- 
pig  exposed  under  similar  circumstances  the  fetus  was  killed. 
Elihu  Thomson,!  in  a  similar  experiment,  exposed  a  healthy 
mouse  for  one  hour  to  powerful  x-rays,  with  the  result  that 
it  died  the  next  day.  Oudin,  Barthelemy  and  Darier  J  have 
reported  two  cases  of  vomiting  in  children,  following  x-ray 

*  Boston  Med.  and  Surg.  Jour.,  1901,  cxliv,  pp.  173,  317. 

t  American  X-ray  Journal,  1898,  iii,  p.  451. 

J  Monatshef te  f .  prakt.  Derm.,  1897,  xxv,  p.  417. 


DEEP-SEATED   X-RAY   EFFECTS.  233 

exposures,  which  are  possibly  attributable  to  the  effect  of  the 
x-rays.  They  also  report  a  man  who  developed  an  acute 
miliary  tuberculosis  while  taking  x-ray  exposures,  and  who 
suffered  much  from  palpitation  and  pain  in  the  heart,  which 
he  attributed  to  the  x-rays.  In  none  of  these  cases  is  the 
evidence  of  the  effect  conclusive.  Walsh*  has  reported  two 
cases  suggesting  deep-seated  effects  of  x-rays.  In  one  case  the 
patient  suffered  from  cerebral  symptoms  suggestive  of  sun- 
stroke. He  had  been  in  the  habit  of  demonstrating  the  x-rays 
and  had  had  repeated  and  prolonged  exposures.  He  had 
from  time  to  time  dermatitis,  and  later  developed  headache, 
vertigo,  vomiting,  dimness  of  sight,  and  great  prostration. 
The  symptoms  were  said  to  be  practically  those  of  sunstroke. 
He  stopped  the  exposures  and  went  to  the  seaside,  and  the 
symptoms  disappeared.  In  the  second  case  an  x-ray  worker 
gave  his  abdomen  long  exposures  repeatedly.  After  some  weeks 
he  complained  of  abdominal  symptoms,  pain,  tenderness, 
flatulency,  diarrhea.  On  removing  to  the  country  these  symp- 
toms disappeared,  but  returned  upon  renewing  the  work.  He 
then  shielded  his  abdomen  with  sheet-lead,  and  the  symptoms 
finally  disappeared.  Another  evidence  of  the  deep-seated  effect 
of  x-rays  is  found  in  the  relief  of  pain  due  to  deep-seated  patho- 
logical processes.  This  anodyne  effect  of  x-rays  is  unmistakably 
manifest  in  various  deep-seated  pathological  processes  subjected 
to  x-ray  exposures. 

Scholtz  f  is  inclined  to  doubt  the  possibility  of  such  deep- 
seated  effects,  and  intimates  that  they  may  be  due  to  suggestion. 
This  hardly  seems  to  cover  the  situation.  The  writers  who 
have  reported  these  cases  are  careful,  trained  observers,  not 
likely  to  be  misled;  and,  in  addition,  the  occurrences  are  by 
no  means  impossible.  The  fact  of  the  relief  of  deep-seated 
pain  by  x-rays  is  sufficient  to  indicate  the  possibility  of  x-rays 
producing  an  impression  upon  deep-seated  tissues;  and  as  to 
this  relief  at  times  of  deep-seated  pain  by  x-rays  there  can 
be  no  manner  of  doubt.  This  has  happened  frequently  in 

*"The  Rontgen  Rays  in  Medical  Work,"  Wm.  Wood  Co.,  N.  Y.,  1902,  pp. 
205,  206. 

t  Arch.  f.  Derm.  u.  Syph.,  1902,  lix,  p.  87. 


234  THE    EFFECTS    OF   X-RAYS    ON    TISSUES. 

my  experience,  and  under  conditions  where  the  possibility 
of  suggestion  and  other  factors  could  be  ruled  out.  Other 
symptoms,  as  vomiting,  vertigo,  and  prostration,  I  have  not 
observed,  although  I  have  had  considerable  experience  with 
x-ray  burns  in  locations  where  such  symptoms  might  have  been 
expected.  This  matter  of  deep-seated  x-ray  effect  is  of  the 
utmost  importance.  If  it  could  be  demonstrated  that  as  great 
effect  can  be  produced  by  x-rays  upon  deep  tissues  as  is  pro- 
duced upon  the  tissues  overlying  them,  it  would  be  of  course 
of  the  highest  significance  in  the  question  of  treatment  with 
x-rays  of  deep-seated  pathological  conditions.  Unfortunately 
it  is  surely  true  that  the  effect  upon  deeper  tissues  can  never 
be  as  great  as  upon  those  overlying  them.  The  quantity  of 
x-rays  that  reaches  a  given  surface  is  inversely  as  the  square 
of  the  distance;  in  addition,  a  certain  quantity  of  x-rays  must 
be  absorbed  by  every  overlying  tissue,  so  that  for  both  of  these 
reasons  it  is  impossible  that  as  great  effect  should  be  produced 
in  deep-seated  tissues  as  in  those  that  cover  them. 

Time  of  First  Appearance  of  Symptoms. — The  time  of  the 
first  evidence  of  x-ray  effects  upon  the  tissues  varies  from 
the  appearance  of  symptoms  at  the  time  of  exposure  or  a  few 
hours  later  to  several  weeks  thereafter.  In  a  few  cases  it  is 
recorded  that  evidence  of  irritation  showed  itself  at  the  time 
of  exposure.  In  a  case  reported  by  Fuchs  *  vesicles  developed 
fifteen  minutes  after  exposure.  In  the  vast  majority  of  cases, 
however,  the  first  appearance  is  from  three  to  fifteen  days 
after  exposure.  Upon  this  point  Codman,f  in  a  very  thoughtful 
critical  review  of  x-ray  injuries,  which  comprehends  all  recorded 
cases,  makes  the  following  statement : 

"The  impression  has  prevailed  that  these  lesions  usually 
make  their  first  appearance  only  after  a  number  of  days.  The 
following  is  a'  table  of  the  records  as  to  this  point : 

*Deutsch.  med.  Wochenschr.,  1896,  xxii,  p.  569. 
tPhila.  Med.  Jour.,  1902,  ix,  pp.  438  and  499. 


TIME    OF    FIRST   APPEARANCE    OF    SYMPTOMS. 


235 


"n  9  instances   signs  or  symptoms  were  noticed  within       24  hours 

6 

' 

2  days 

6 

' 

3  days 

2 

< 

4  days 

5 

' 

5  days 

3 

6  days 

3 

t 

7  days 

4 

' 

8  days 

2 

t 

9  days 

9 

' 

10  days 

8 

' 

10-14  days 

8 

' 

'     15-21  days 

2 

t 

'    22-28  days 

3 

i 

after  the  fourth  week 

70 

These  figures  indicate  that  at  least  in  a  good  proportion  of 
the  cases  the  first  symptoms  are  noticed  within  the  first  few 
days  after  the  exposure.  Three  are  mentioned  as  being  noticed 
immediately  after  the  exposure.  It  seems  possible  that  the 
reason  that  so  many  are  first  noticed  in  the  second  and  third 
weeks  is  that  it  is  at  this  time  that  the  sensitiveness  of  the 
lesion  becomes  severe  enough  to  attract  the  attention  of  the 
patient.  In  some  cases,  however,  this  late  appearance  is  well 
substantiated;  e.  g.,  in  the  cases  of  Thomson,  Orleman,  and 
Barthelemy.  But  five  cases  of  my  series — Cases  3,  4,  41,  126, 
and  147 — appeared  later  than  twenty-one  days.  It  is  unfor- 
tunate that  we  have  not  more  accurate  reports  of  them." 

Other  studies  upon  this  point  give  practically  the  same 
findings,  as  will  be  seen,  for  example,  by  reference  to  the  tables 
of  Gilchrist  *  and  Scott. f  In  a  personal  experience  covering 
several  hundred  cases  I  have  never  seen  a  reaction  occur  as 
late  as  three  weeks  after  exposure.  In  the  171  cases  of  x-ray 
burns  which  Codman  is  able  to  find,  he  states  that  five  of  these, 
and  but  five,  developed  later  than  twenty-one  days  after  ex- 
posure. I  am  able  to  find,  however,  on  analysis  of  his  cases, 
only  three  that  developed  more  than  twenty-one  days  after 
exposure.  Of  these,  two  cases,  Dale's  and  Scott's,  are  given 
as  developing  four  weeks  after  exposure,  and  one,  Stinson's, 
between  three  and  six  weeks  after  exposure.  In  Dale's  case 

* Johns  Hopkins  Hosp.  Bull.,  1897,  viii,  p.  17. 
t  Trans.  Ohio  State  Med.  Society,  1897,  lii,  p.  139. 


236  THE    EFFECTS   OF  X-RAYS   ON   TISSUES. 

there  was  a  moist  dermatitis,  which  appeared  twenty-eight 
days  after  exposure,  and  lasted  for  a  short  time.  Stone  Scott's 
case  was  a  personal  report  to  Codman  of  an  unpublished  case, 
and  the  time  of  the  development  was  given  as  four  weeks. 
In  Stinson's  case  a  fracture  was  exposed  to  x-rays,  and  three 
weeks  later  a  plaster  cast  was  applied.  Six  weeks  later  there 
was  a  purulent  dermatitis  under  the  plaster.  It  is  apparently 
not  excluded  in  this  case  that  the  dermatitis  was  not  a  der- 
matitis such  as  is  often  seen  under  plaster  casts.  Barthelemy's 
case,  which  is  given  as  a  case  with  the  development  of  an  x-ray 
injury  five  months  after  exposure,  on  examination  shows  that 
the  primary  skin  effect  was  by  no  means  so  late.  The  patient 
had  several  x-ray  exposures,  which  produced  no  reddening  of 
the  skin,  but  did  cause  pigmentation,  followed  by  slight 
desquamation  at  the  end  of  treatment.  Five  months  later 
an  irritated  patch  developed,  with  hypervascularization  and 
redness  and  desquamation.  The  lesion  occurring  five  months 
after  exposure,  therefore,  was  not  the  first  x-ray  effect  on  the 
skin.  That  there  was  an  inflammatory  process  at  the  time 
of  the  pigmentation  is  shown  by  the  subsequent  desquamation. 
His  case,  accordingly,  should  be  included  in  the  class  of  cases 
in  which  there  has  been  a  relapse  of  dermatitis  some  time 
after  the  original  irritation,  two  examples  of  which  I  have 
reported  on  pages  342  and  344. 

When  one  takes  into  consideration  the  chances  of  error  as 
regards  time  of  development  of  these  burns,  it  will  be  seen 
that  the  evidence  in  favor  of  the  development  of  x-ray  injuries 
more  than  three  weeks  after  date  of  exposure  is  not  very  strong. 
Only  three  cases  are  to  be  found.  In  none  of  these  is  the 
evidence  conclusive,  and  in  none  except  Stone  Scott's,  in  which 
there  is  said  to  have  been  "dermatitis  with  ulceration,"  was 
the  injury  at  all  serious.  It  appears  on  the  whole,  therefore, 
that  it  may  be  stated  with  reasonable  accuracy  that  the  devel- 
opment of  x-ray  burns  is  practically  always  within  three  weeks 
after  the  last  exposure. 

Duration  of  X-ray  Burns. — There  is  a  paucity  of  data  in 
the  literature  concerning  the  duration  of  x-ray  effects,  except 
in  severe  burns  with  necrosis.  My  own  experience  on  this 


DURATION   OF   X-RAY   BURNS.  237 

subject  covers  a  very  considerable  number  of  cases  of  slighter 
degrees  of  x-ray  burns,  from  which  fairly  accurate  data  may 
be  gotten.  Pigmentation  produced  by  x-rays  disappears 
slowly.  In  some  cases,  even  where  the  tanning  was  consider- 
able, I  have  seen  it  disappear  in  two  to  six  weeks.  In  a  few 
other  cases,  not  more  severe,  traces  of  pigmentation  have 
lasted  for  eight  months  before  finally  disappearing.  The 
difference  here  is  probably  simply  one  in  the  pigment-forming 
characteristics  of  the  individual  skins.  The  period  that  elapses 
between  the  time  that  hairs  disappear  and  return  varies  very 
greatly.  In  certain  cases  I  have  seen  the  hairs  begin  to  return 
within  four  weeks  after  their  disappearance.  In  other  cases 
six  to  twelve  weeks  or  longer  may  elapse  before  there  is  evidence 
of  regeneration  of  the  hair  follicles,  and  in  some  cases  return 
of  hair  does  not  occur  after  their  first  outfall  from  x-ray  ex- 
posures. 

In  x-ray  dermatitis  the  duration  of  the  process  depends 
partly  upon  the  intensity  of  the  burn,  but  more  upon  individual 
susceptibility.  A  phenomenon  that  is  sometimes  witnessed 
in  cases  that  are  being  exposed  from  day  to  day  to  x-rays  is 
the  development  of  a  very  slight  erythema  after  exposure 
and  its  disappearance  before  the  exposure  of  the  next  day. 
This  is  a  condition  that  sometimes  precedes  the  development 
of  the  ordinary  dermatitis.  In  cases  of  moderate  dermatitis 
without  vesiculation  the  process  usually  increases  for  five  or 
six  days,  then  remains  stationary  for  a  few  days,  and  then 
undergoes  rapid  involution,  the  whole  cycle  taking  ten  to 
twenty  days.  In  one  case  of  dermatitis  of  the  first  degree  of 
which  I  have  notes  the  effect  increased  slightly  for  four  days 
after  its  appearance,  and  disappeared  entirely  by  the  end 
of  eight  days.  In  another  case  by  the  end  of  four  days  from 
its  appearance  there  was  a  rather  lively  red,  acute,  dry  der- 
matitis, which  remained  unchanged  for  two  days  and  then 
rapidly  subsided,  until  on  the  tenth  day  the  surface  was  entirely 
restored  to  normal  except  for  a  slight  pigmentation.  In  der- 
matitis of  the  second  and  third  degrees  the  process  as  I  have 
seen  it  reaches  its  climax  in  one  to  two  weeks.  For  example, 
in  one  case  of  acute  dermatitis  with  moderate  vesiculation, 


238  THE   EFFECTS   OF  X-RAYS   ON   TISSUES. 

seven  days  after  slight  erythema  was  noticed  the  process  reached 
its  most  acute  stage,  by  the  end  of  fifteen  days  it  was  manifestly 
subsiding,  and  at  the  end  of  twenty-one  days  was  entirely 
gone.  In  another  case,  in  which  the  dermatitis  became  quite 
acute,  there  was  on  the  eighth  day  after  the  first  trace  was 
noticed  an  acutely  inflamed  red  surface  covered  with  vesicles. 
By  the  tenth  day  these  had  ruptured  and  a  necrotic  pellicle 
had  formed  and  covered  the  whole  of  the  raw  surface.  By 
the  twelfth  day  the  line  of  demarcation  of  this  necrotic  mem- 
brane was  sharply  defined.  This  remained  stationary  until  the 
fifteenth  day.  From  the  fifteenth  day  there  was  gradual  con- 
traction of  its  margins,  and  at  the  end  of  forty  days  the  surface 
was  entirely  covered  with  healthy  epidermis.  In  another  case, 
a  little  more  severe  that  the  preceding,  four  days  after  the 
last  exposure  slight  erythema  with  sensation  of  heat  was  no- 
ticed. On  the  tenth  day  from  the  last  exposure  the  surface 
was  congested,  dark  red,  and  angry  looking.  On  the  fourteenth 
day  it  was  covered  writh  vesicles.  On  the  sixteenth  day  there 
was  a  necrotic  membrane  over  a  space  three  inches  square, 
and  one  day  later  the  line  of  demarcation  of  this  membrane 
was  well  marked.  The  condition  remained  stationary  for  about 
five  days,  or  until  the  twenty-second  day,  after  which  it  gradually 
contracted,  until  on  the  forty-second  day  the  surface  was 
entirely  covered  with  healthy  epidermis  with  just  a  trace  of 
redness  left. 

Relapses. — In  three  rather  severe  cases  of  dermatitis,  each 
accompanied  by  the  formation  of  a  superficial  necrotic  mem- 
brane, relapses  occurred  in  each  case  approximately  two  months 
after  the  disappearance  of  the  first  dermatitis.  In  one  of  these 
cases  there  was  a  second  relapse  six  months  after  the  first 
dermatitis.  In  none  of  these  cases  was  the  relapse  so  acute 
as  the  first  attack.  In  two  of  the  cases  the  recurrence  was 
indistinguishable  from  a  vesicular  eczema.  Indeed  it  is  not 
established  that  the  apparent  relapse  was  not  a  dermatitis 
from  external  irritation  in  a  surface  of  the  skin  whose  normal 
tolerance  had  not  yet  been  reestablished.  In  both  of  these 
cases  eczema  developed  symmetrically  on  other  parts  of  the 
body.  In  the  third  case,  however,  the  recurrence  was  unques- 


CUMULATIVE    EFFECTS.  239 

tionably  an  x-ray  dermatitis  of  a  character  similar  to  but  milder 
than  the  first  attack.  This  case  showed  the  recurrence  at  the 
end  of  two  months.  There  was  considerable  congestion  of 
the  area,  which  was  covered  with  gray  horny  epidermis  with 
numerous  weeping  patches.  This  was  a  case  of  epithelioma 
treated  by  x-rays,  in  which  before  any  effect  was  produced 
upon  the  lesion  the  effect  upon  the  skin  had  to  be  carried  to 
an  extreme  point. 

As  to  the  duration  of  burns  with  necrosis  of  the  connective 
tissue,  it  is  well  known  that  they  last  for  a  very  long  time — 
from  one  or  two  months  to  a  year  or  more,  depending  largely 
upon  the  severity  of  the  burn.  A  case  of  carcinoma  exposed 
to  x-rays,  which  I  have  reported  (Case  119),  is  interesting 
in  connection  with  this  question  of  the  duration  of  x-ray 
effects  upon  the  tissues.  In  this  case  the  carcinoma  involved 
the  entire  orbit.  Exposures  were  continued  for  two  months, 
with  the  production  of  a  very  acute  dermatitis,  but  without 
any  apparent  effect  upon  the  growth.  Treatment  was  there- 
upon discontinued,  but  in  spite  of  the  fact  that  the  patient 
had  no  further  exposures  the  tumor  continued  to  shrink  for 
five  months,  and  until  it  had  almost  entirely  disappeared. 
A  consideration  of  this  question  leaves  no  room  for  doubt 
that  persistence  is  a  marked  characteristic  of  the  reaction 
produced  by  x-rays  on  tissues.  This  quality  has  proved  most 
troublesome  in  accidental  x-ray  burns.  It  must  be  reckoned 
with,  and  it  may  be  used  to  good  advantage  in  the  therapeutic 
application  of  x-rays. 

Cumulative  Effects. — It  is  a  necessary  corollary  of  the  fore- 
going that  the  effects  of  x-rays  are  cumulative  when  the  sittings 
are  often  repeated.  For,  since  there  is  a  period  of  incubation 
lasting  several  days,  and  since  the  effects  themselves  continue 
for  many  days,  it  follows  necessarily  that  exposures  repeated 
during  either  of  these  periods  must  increase  the  effect  upon 
the  tissues.  This  cumulative  action  of  repeated  x-ray  exposures 
is  practically  universally  accepted  and  needs  no  extended 
discussion.  It  must  be  taken  carefully  into  consideration  in 
any  attempt  to  give  repeated  exposures. 

Idiosyncrasies. — According  to  almost  universal  opinion  there 


240  THE    EFFECTS   OF  X-RAYS   ON   TISSUES. 

is  a  marked  difference  in  the  way  in  which  tissues  of  different 
individuals  react  to  the  influence  of  x-rays.  The  only  radical 
exception  to  this  opinion  that  I  know  of  is  that  of  Kienbock,* 
who  takes  the  position  that  "we  are  not  justified  in  assuming 
an  idiosyncrasy  to  x-rays. "  f  He  goes  even  further,  and  states  J : 
"A  fact  of  the  greatest  importance,  from  a  therapeutic  stand- 
point, is  the  knowledge  that  individuals  in  good  health  react 
in  precisely  a  similar  manner  to  x-ray  radiance.''  And  he 
builds  an  x-ray  technique  around  this  theory.  In  my  judgment 
there  is  not  the  slightest  suspicion  of  evidence  to  justify  such 
a  statement.  The  very  fact  that  x-ray  burns  are  comparatively 
so  few  demonstrates  in  the  largest  and  most  convincing  way 
the  inaccuracy  of  such  a  position.  It  is  literally  true  that 
at  the  present  time  millions  of  x-ray  exposures  have  been 
made,  and  most  cases  of  burn  of  a  severe  character  come  to 
light;  yet  Codman  in  considering  the  subject  of  x-ray  injuries 
is  able  to  find  recorded  in  all  the  literature  only  170  burns. 
Gilchrist,§  in  reviewing  the  literature  in  February,  1897,  was 
able  to  collect  only  23  cases,  and  Stone  Scott,  ||  in  reviewing 
the  subject  in  May,  1897,  was  able  to  find  only  69  cases.  With 
the  hundreds  of  thousands  of  x-ray  exposures  that  have  been 
made,  is  it  to  be  supposed  that  only  170  cases  have  been  exposed 
beyond  the  point  of  safety?  Or  even  suppose  that  only  one 
in  ten  cases  of  severe  burn  has  come  to  light,  is  it  to  be  supposed 
that  only  1700  cases  of  over-exposure  have  taken  place?  The 
supposition  is  an  absurdity  on  the  face  of  it.  Probably  in 
one  month,  three  or  four  months  after  Rontgen's  discovery 
was  announced,  over  seventeen  hundred  cases  were  exposed 
in  a  way  that  we  now  know  to  be  dangerous.  Many  cases 
of  burn  have  unquestionably  been  caused  by  dangerous  expo- 
sures; on  the  other  hand,  it  is  certainly  true  that  thousands 
of  what  are  dangerous  exposures  for  some  individuals  have 
been  made  without  injury.  And  the  fact  that  in  innumerable 

*  Wiener  klin.  Wochenschr.,  1900,  xiii,  p.  115:>;  Wiener  med.  Presse,  1901, 
xlii,  p.  873. 

t  Interstate  Medical  Journal,  1902,  ix,  pp.  1,  60. 
2  Johns  Hopkins  Hosp.  Bull.,  1897,  viii,  p.  17. 
||  Trans.  Ohio  State  Med.  Society,  1897,  Hi,  p.  1P>9. 


QUESTION   OF   DANGEROUS   AND   SAFE    EXPOSURES.          241 

cases  the  individuals  have  escaped  x-ray  effects,  while  in  a 
few  cases  under  similar  conditions  injuries  have  occurred, 
can  be  accounted  for  only  by  the  existence  in  a  few  individuals 
of  certain  factors  rendering  them  more  susceptible  to  re-ray 
influence.  Such  a  statement  as  Kienbock's,  founded  as  it 
is  absolutely  upon  personal  opinion  regardless  of  recorded 
facts,  needs  to  be  challenged.  It  is  most  mischievous  in  the 
influence  which  it  may  have  upon  technique;  and  there  are 
enough  x-ray  injuries  due  to  faulty  technique  without  throwing 
out  so  well-established  a  fact  as  personal  idiosyncrasy  to  account 
for  some  of  them. 

Question  of  Dangerous  and  Safe  Exposures. — Codman  *  has 
considered  more  extensively  than  any  one  else  the  question 
of  the  intensity  of  x-ray  exposures  which  have  caused  injury 
in  the  various  recorded  cases.  His  table  covers  this  subject 
more  recently  and  more  extensively  than  any  other  has  done, 
and  it  is  worthy  of  reproduction  (see  page  242)  as  bearing  upon 
this  extremely  important  topic. 

In  this  table  it  is  seen  that  the  exposure  required  to 
produce  injury  in  cases  recorded  varies  from  0.08  of  a  minute 
at  one  inch  distance,  to  240  minutes  at  one  inch  distance. 
Assuming  that  the  light  in  both  cases  was  the  same,  here  is 
a  variation  of  3000  units  between  the  susceptibility  of  the 
two  patients.  Of  course  it  cannot  be  rightly  assumed  that 
the  light  in  both  cases  was  the  same,  but  it  can  be  easily  assumed 
that  the  light  in  the  one  case  was  not  3000  times  or  even  300 
times  as  great  as  it  was  in  the  other.  In  contradistinction  to 
this  case,  where  an  exposure  equivalent  to  0.08  of  a  minute 
at  one  inch  distance  caused  a  severe  dermatitis,  E.  E.  King  f 
records  a  case  of  exposure  of  the  hands  for  three  to  four  months 
for  from  two  to  six  hours  daily  before  x-ray  effects  developed. 
I  have  in  my  records  one  case  (Case  37)  in  which  243  exposures, 
equivalent  to  one-half  minute  at  one  inch  distance  from  the 
target,  were  given  in  the  course  of  sixteen  months,  without 
at  any  time  causing  more  than  slight  dermatitis. 

In  the  therapeutic  use  of  x-rays  when  one  has  occasion  to 

*Phila.  Med.  Jour.,  1902,  ix,  p.  438. 
t  Canadiau  Practitioner,  1896,  xxi,  p.  789. 
16 


NO.   OF 

CASE. 

INCHES  FROM 
TUBK. 

EXPOSURE  IN 
MINUTES. 

DAYS  OF 
INCUBATION. 

SEVERITY. 

COMPARATIVE 
TIME  AT  1  INCH  — 
MINUTES. 

102 

19.68 

30 

1 

severe 

0.08 

72 

15.00 

30 

14 

mild 

0.13 

66 

11.81 

25 

severe 

0.18 

113 

10.00 

20 

7 

medium 

0.20 

97 

10.00 

21 

21 

severe 

0.21 

112 

8.00 

15 

3hrs. 

medium 

023 

124 

6.00 

20 

2hrs. 

medium 

0.55 

16 

10.00 

60 

6 

severe 

0.60 

87 

3-4 

10 

14 

severe 

1.11  or  0.63 

38 

8.00 

45 

severe 

0.70 

96 

3.94 

17 

8 

medium 

1.11 

75 

7.88 

78 

severe 

1.27 

19 

(patient  6  in.) 

(oper.  15.32) 

1.43  or  8.88 

49 

5.40 

45 

14 

severe 

1  50 

45 

5.85 

52 

medium 

1.51 

57 

G.24 

60 

during 

medium 

1.54 

62 

6.00 

60 

14 

severe 

1.66 

33 

5.00 

45 

7 

severe 

1.80 

156 

6.00 

75 

o 

severe 

2.08 

39 

5.00 

60 

1 

severe 

2.40 

52 

4.29 

45 

2 

severe 

2.44 

85 

11.00 

300 

severe 

2.48 

63 

8.00 

180 

10 

medium 

2.81 

53 

3.94 

50 

5 

mild 

3.28 

41 

3.00 

30 

28 

medium 

3.33 

127 

2.  00  or  1.00 

15 

10 

medium 

3.75  or  15.00 

139 

4.00 

60 

10 

severe 

3.75 

132 

2-8  in. 

300 

at  once 

severe 

75.00  or  4.69 

148 

1.5  cm. 

25 

1 

severe 

162.50  or  5.32 

125 

6.00 

270 

21 

severe 

7.50 

126 

6.00 

270 

21 

severe 

7.50 

54 

3.94 

120 

3 

mild 

7.89 

1 

15  cm.  for 

40 

2 

severe 

8.51 

9  cm.  for 

90 

143 

3.00 

1.50,  1.20 

o 

severe 

16.66  or  11.11 

71 

3.94 

2.10 

severe 

13.80 

149 

1.25 

30 

9 

severe 

19.20 

59 

1.96 

80 

severe 

21.05 

105 

3.00 

200 

during 

medium 

2-2.22 

15 

1  (?) 

30 

5 

severe 

30.00 

153 

(1.625 

12 

11 

medium 

30.23 

47 

2.00 

150 

2 

severe 

37.50 

55 

.1.94 

1200 

mild 

78.90 

141 

0.39 

20 

6 

severe 

129.00 

4() 

0.50 

60 

21 

mild 

240.00 

"NOTE. — The  writer  is  fully  aware  that  these  figures  are  far  from  accurate, 
owing  to  the  lack  of  proper  data  in  distance  from  the  platinum  or  glass  wall. 
For  instance,  in  the  last  two  numbers,  if  we  allow  an  inch  for  the  radius  of  the 
tube,  we  find  that  the  time  in  minutes  at  one  inch  would  read  10.53  and  26.60, 
instead  of  129  and  240.  In  the  cases  in  which  the  distance  is  considerable  the 
change  would  not  be  so  great.  The  figures  are  poor  at  best,  and  serve  more  to 
suggest  a  method  of  comparison  for  the  future,  than  an  as  absolute  figures  for 
the  past The  minimum  recorded  exposure  which  has  produced  in- 
jury is  then  (Case  102)  equivalent  to  only  0.08  of  a  minute  or  5  seconds  at  one 

inch This  figure  may  be  assumed  to  represent  the  extreme  grade 

of  idiosyncrasy  on  the  part  of  any  patient  hitherto  examined — one  case  in  a 
million." 

242 


QUESTION    OF    DANGEROUS   AND    SAFE    EXPOSURES.  243 

give  exposures  daily  or  very  frequently  over  a  long  period 
of  time  the  opportunity  to  observe  personal  idiosyncrasy  is 
excellent.  It  has  been  my  constant  experience  to  see  variations 
in  the  susceptibility  of  the  tissues  of  different  individuals  to 
the  influence  of  x-rays.  One  patient  will  develop  x-ray  irrita- 
tion after  repeated  exposures  during  two  weeks.  Another 
patient,  under  conditions  of  technique  which  are  as  nearly 
identical  as  care  can  make  them,  will  not  develop  a  similar 
irritation  until  two  months  have  passed.  He  may  then  develop 
a  reaction  which  is  no  greater,  which  runs  no  longer  course, 
and  which  differs  in  no  essential  particular  in  degree  or  character 
from  the  reaction  of  the  other  individual,  which  was  set  up 
at  the  end  of  two  weeks  of  similar  exposure.  This  variation 
in  the  susceptibility  of  individuals  to  the  influence  of  x-rays 
is  a  fact  beyond  question.  Any  extended  observation  upon 
cases  under  treatment  by  exposure  to  x-rays  must  establish 
it.  And  this  fact  must  be  taken  into  consideration  in  the 
application  of  the  agent.  It  is  the  one  fact  whose  avoidance 
requires  the  most  care  in  the  application  of  x-rays  to  therapeutic 
purposes. 

The  variation,  however,  in  the  susceptibility  of  individuals 
to  x-ray  effects  has  never  been  sufficient  in  my  experience 
to  amount  to  marked  idiosyncrasy.  The  variation  which  I 
have  mentioned  above,  which  may  perhaps  be  said  with  suffi- 
cient accuracy  to  amount  to  a  difference  of  four  times  the 
susceptibility  in  one  case  over  that  in  another,  is  about  as 
extreme  variation  as  I  have  seen  in  my  experience  with  very 
few  exceptions,  such  as  the  case  mentioned  above,  in  which 
243  exposures  were  given  in  sixteen  months. 

It  may  be  said,  therefore,  I  believe,  that  a  moderate  variation 
in  the  susceptibility  of  individuals  is  constantly  found,  but 
that  this  difference  rarely  amounts  to  more  than  four  times 
as  great  susceptibility  in  one  individual  as  in  another.  In 
extremely  rare  instances  this  susceptibility  amounts  to  a 
marked  idiosyncrasy,  but  this  idiosyncrasy  is  excessively  rare. 
On  the  basis  of  Codman's  statistics,  for  example,  it  occurs 
less  frequently  than  once  in  ten  thousand  individuals. 

There  have  been  some  suggestions  that  different  parts  of 


244  THE    EFFECTS    OF    X-RAYS    OX    TISSUES. 

the  body  in  the  same  individual  vary  in  their  susceptibility. 
Kienbock  *  states  that  "the  different  regions  of  the  surface 
of  the  body  react  in  a  varying  manner.  The  mucous  mem- 
branes react  most  rapidly,  and  in  order  of  lessening  rapidity 
the  skin  of  the  face,  of  the  backs  of  the  hands,  the  nail  matrices, 
the  skin  of  the  extremities,  and  of  the  trunk.  Over  the  hairy 
surface  of  the  head  the  hair  comes  out  very  easily  without 
the  appearance  of  any  sign  of  erythema;  there  the  skin  is 
tightly  bound  down  to  the  underlying  tissue — and  the  more 
tense  it  is,  the  less  is  the  tendency  to  superficial  inflammatory 
appearances."  Scholtz  |  also  suggests  similar  variations  of 
different  parts  of  the  body.  Most  other  observers  have  not 
found  such  variability.  Certainly  I  have  not  found  it  myself. 
The  parts  that  are  tanned  by  exposure  to  sunlight  react  perhaps 
a  little  less  readily  than  covered  parts,  but  even  this  is  not 
established.  Indeed  my  experience  does  not  give  any  ground 
for  the  supposition  that  different  parts  of  the  skin  differ  in 
any  material  extent  in  their  reaction  to  the  influence  of  x-rays. 
I  have  not  even  found  that  individuals  with  delicate  fair  skins 
are  liable  to  show  greater  susceptibility  to  x-rays  than  indi- 
viduals with  darker  or  more  tolerant  skin.  Variations  in  these 
particulars  seem  to  be  purely  a  matter  of  personal  equation 
of  the  tissues  without  discoverable  characteristics  upon  which 
increased  susceptibilit}''  or  decreased  susceptibility  may  be 
predicated. 

The  only  part  which  I  have  found  to  show  particular  sus- 
ceptibility to  x-rays  is  the  eyes,  and  this  of  course  is  due  to 
their  peculiar  structure.  Cases  of  conjunctivitis  from  x-rays 
have  been  reported  by  King  J  and  Scherer.§  Scherer's  patient 
also  had  an  incipient  retinitis,  which  he  thought  was  due 
to  x-rays.  Conjunctivitis  is  readily  produced  by  x-rays,  and 
the  process,  by  involving  the  cornea,  may  become  dangerous 
to  sight.  Following  the  suggestion  of  Oudin,  Barthelemy, 
and  Darier,  that  the  most  highly  differentiated  epithelial 

*Wien.  klin.  Wochenschr.,  1900,  xiii,  p.  1153. 
f  Arch.  f.  Derm.  u.  Syph.,  1902,  lix,  p.  241. 
J  Canadian  Practitioner,  1896,  xxi,  p.  789. 
\  New  York  Med.  Jour.,  1901,  Ixxiv,  p.  543. 


IMMUNITY.  245 

elements  were  most  susceptible  to  x-rays,  I  *  called  attention 
to  the  possibility  of  atrophy  of  the  rods  and  cones  of  the  retina 
from  x-ray  exposures.  Apparently  that  danger  was  more 
theoretical  than  practical,  for  the  effect  upon  the  conjunctiva 
and  cornea  will  in  all  probability  become  severe  before  the 
effect  will  show  on  the  retina.  Scholtz  f  upon  this  particular 
point  believes  that  the  only  effect  produced  on  the  eyes  by 
x-rays  is  conjunctivitis,  and  that  there  is  no  effect  on  the 
retina. 

Influence  of  Other  Factors  on  Susceptibility. — Various  factors 
in  the  patient  have  been  called  upon  to  explain  variations  in 
susceptibility,  as,  for  example,  variations  "in  the  dryness  or 
dampness  of  his  skin;  in  his  electrical  resistance;  in  his  anemia 
or  plethora;  in  the  acidity  or  alkalinity  of  his  sweat;  in  his 
vasomotor  irritability.''!  In  my  experience  I  have  not  been 
able  to  determine  the  influence  of  any  such  factors.  I  have 
repeatedly  exposed  cases  showing  the  widest  variations  in  the 
conditions  of  the  skin ;  surfaces  that  were  unbroken  and  surfaces 
that  were  ulcerated;  skins  that  were  clean  and  skins  that  were 
dirty  or  covered  with  medicine ;  skins  that  were  dry  and  skins 
that  were  covered  with  sweat;  patients  that  were  markedly 
cachectic  and  patients  that  were  healthy; — and  I  have  never 
seen  any  reason  to  believe  that  any  of  these  factors  was  of 
appreciable  importance  in  determining  the  production  of  x-ray 
effects  on  the  skin. 

Immunity. — Lancashire  §  has  offered  the  opinion  that  the 
production  of  dermatitis  is  a  matter  of  idiosyncrasy,  and  that 
immunity  against  it  may  develop.  I  have  seen  nothing  in  my 
experience  to  give  color  to  the  opinion  that  immunity  is  likely 
to  develop.  I  have  never  seen  any  reason  to  believe  that 
patients  become  more  tolerant  of  x-rays  after  being  for  a  long 
time  under  their  influence  than  they  were  at  the  start.  On 
the  contrary,  it  has  seemed  to  me  that  an  increased  suscepti- 
bility developed,  and  certainly  it  is  easier  to  produce  dermatitis 
after  a  previous  dermatitis  has  occurred,  unless  a  sufficient 

*  Jour.  Amer.  Med.  Assoc.,  1902,  xxxviii,  p.  911. 

t  Arch.  f.  Derm.  u.  Syph.,  1902,  lix,  p.  99. 

JCodman,  loc.  cit.  \  Brit.  Med.  Jour.,  1902,  i,  1328. 


246  THE    EFFECTS    OF   X-RAYS    OX    TISSUES. 

time  has  elapsed  for  the  tissues  entirely  to  regain  their  normal 
condition. 

Anodyne  Effect  of  X-rays. — Many  observers  have  called 
attention  to  the  marked  anodyne  effect  of  x-rays  in  painful 
conditions.  The  relief  of  pain  in  carcinoma  has  been  noted 
by  various  observers;  among  others:  Sequeira,*  Pfahler,t  John- 
son and  Merrill,  J  Ayers,§  Ferguson,  ||  Clark,**  Soiland,ft 
Eijkman,|t  Morton,  §§  Despeignes,  |!  |  and  Gocht.***  The  cases 
in  which  this  effect  has  been  observed  vary  from  epitheliomata 
to  extensive  and  deep-seated  carcinomata.  Despeignes,  so 
early  as  1896,  reported  the  relief  of  pain  in  carcinoma  of  the 
stomach.  Similar  marked  effect  in  relieving  the  pain  of  sar- 
coma has  been  reported  by  Kirby,ttt  Ricketts,JJJ  Burdick,§§§ 
Coley,  ||  ||  ||  and  others. 

The  anodyne  effects  of  x-rays  are  not  confined  to  malignant 
diseases.  Sokolow  ****  has  reported  the  marked  relief  of  pain 
in  rheumatism.  Escherich  de  Graz  fttt  reports  the  relief  of 
pains  of  rheumatoid  arthritis.  Gocht  JJJJ  has  reported  a  very 
severe  case  of  trigeminal  neuralgia,  for  which  the  patient  had 
used  morphin,  which  was  entirely  relieved  by  fourteen  x-ray 
exposures.  Stembo  §§§§  has  reported  twenty-eight  cases  of 
various  forms  of  neuralgic  conditions,  of  which  twenty-one,  or 
75  per  cent.,  were  promptly  relieved.  Relief  usually  followed 

*Brit.  Med.  Jour.,  1901,  ii,  851.  f  Phila.  Med.  Jour.,  1901,  viii,  1085. 

J  Phila.  Med.  Jour.,  1900,  vi,  p.  1089. 
$K.  C.,  Medical  Index-Lancet,  1902,  xxiii,  p.  18. 

||  Brit.  Med.  Jour.,  1902,  i,  p.  265.  **  Brit.  Med.  Jour.,  1901,  i,  p.  1398. 

ft  South.  Cal.  Practitioner,  1902,  xvii,  p.  140. 
ItKrebsund  Rontgenstrahlen,  Haarlem,  1902. 

|?  Med.  Record,  1902,  Ixi,  p.  361.  ||||  Semaine  Medicale,  1896,  xvi,  146. 

***  Fortschr.  a.  d.  Geb.  d.  Rontgenstrahlen,  1897,  i,  14. 
ttt  Journal  of  Advanced  Therapeutics,  1902,  xx,  p.  89. 
J+i  Jour.  Am.  Med.  Assoc.,  1900,  xxxiv,  p.  76. 

.\\\  American  Electro-Therapeutic  and  X-Ray  Era,  1901,  i,  No.  7,  p.  1. 
||  ||  ||  American  Medicine,  1902,  iv,  p.  251. 

****Russky  Vratch,  1897,  No.  46.  Abst.  Fortsch.  a.  d.  Geb.  d.  Rontgen- 
strahlen, 1898,  i,  p.  209. 

tftt  Revue  des  maladies  de  1'enfance,  1898,  xvi,  p.  242. 
Jttt  Fortschr.  a.  d.  Geb.  d.  Rontgenstrahlen,  1897,  i,  p.  14. 
\\\\  Therapie  der  Gegenvvart,  1900,  ii,  p.  250. 


ANODYNE    EFFECT   OF   X-RAYS.  247 

three  exposures.  Leigh  *  has  reported  a  case  of  a  young  man 
who  had  a  bullet  in  his  thigh,  which  was  much  swollen  and 
extremely  painful;  the  next  day,  after  a  long  exposure  to 
x-rays,  made  for  the  purpose  of  taking  a  photograph,  the  pain 
was  relieved,  and  on  the  third  day  the  man  was  able  to  walk. 
The  relief  of  itching  in  eczema  and  in  lichen  planus  has  been 
reported  by  Scholtz,f  and  similar  relief  in  eczema  has  been 
reported  by  Hahn  and  Albers-Schonberg.  | 

Variations  from  the  normal  in  the  sensibility  of  parts  affected 
by  x-rays  have  been  noted  by  several  observers.  Gilchrist  § 
and  Oudin,  Barthelemy,  and  Darier||  have  called  attention 
to  the  loss  of  sensibility  in  x-ray  burns  under  their  observation. 
Prince  **  reported  upon  this  point  in  the  case  of  a  burn  of  the 
back  of  his  hand,  as  follows:  "The  sense  of  touch  is  affected 
throughout  the  entire  area  of  inflamed  skin  on  the  dorsal  aspect 
of  the  fingers  of  the  left  hand.  It  is  completely  lost  on  this 
surface  of  the  second  and  third  phalanges  of  the  index,  middle, 
and  ring  fingers,  and  gradually  shades  into  normal  cutaneous 
sensibility  over  the  proximal  phalanx  of  each  of  these  fingers. 
The  little  finger  of  this  hand  shows  hypesthesia  near  the  tip 
only.  In  the  anesthetic  areas  a  needle  point  is  felt  slightly 
as  a  touch,  and  this  hypalgesia  shades  into  normal  sensibility 
to  pain  pari  passu  with  the  restoration  of  touch  sense.  On 
the  sides  of  the  fingers  pain  and  touch  are  felt  normally.  Heat 
and  cold  are  appreciated  with  equal  readiness  in  either  hand." 
Hyperesthesia  has  been  noted  by  Barthelemy  ff  m  a  case  m 
which  there  was  no  anesthesia  but  points  of  hyperesthesia. 

The  testimony  as  to  the  relief  of  pain  by  the  use  of  x-rays 
is  almost  universal  among  workers  in  this  field.  I  have  had 
repeated  opportunities  to  observe  it  in  my  experience.  It 
constantly  happens  that  patients  suffering  from  painful  diseases 
voluntarily  state,  after  a  few  exposures,  that  the  pain  is  greatly 

*  American  X-ray  Journal,  1899,  iv,  p.  559. 

fArch.  f.  Derm.  u.  Syph.,  1902,  lix,  p.  421. 

JMiinchen  med.  Wochenschr. ,  1900,  xlvii,  pp.  284,  324,  3G3. 

I  Johns  Hopkins  Hosp.  Bull.,  1897,  viii,  p.  17. 

||  Monatshefte  f.  prakt.  Derm.,  1897,  xxv,  p.  417. 
**  Phila.  Med.  Jour.,  1902,  x,  p.  199. 
ft  Annales  de  Dermatologie,  1901,  xxxii,  4e  Serie,  vol.  ii,  p.  174. 


248  THE    EFFECTS   OF   X-RAYS   ON    TISSUES. 

or  entirely  relieved.  This  relief  is  not  confined  to  superficial 
conditions,  but  has  been  seen  in  deep-seated  painful  conditions 
as  well.  This  occurrence  is  too  frequent  and  too  positive  to 
be  a  coincidence  or  the  result  of  suggestion.  It  is  rare  for 
painful  malignant  diseases  not  to  be  somewhat  relieved  by 
x-ray  exposures,  and  frequently  after  two  or  three  exposures 
the  relief  will  be  complete,  and  may  persist  as  long  as  the 
exposures  are  continued,  and  perhaps  for  weeks  after  they 
are  stopped.  Were  this  relief  of  pain  seen  only  in  malignant 
diseases,  it  might  be  possible  that  the  effect  was  only  produced 
indirectly  by  interference  with  the  growth  of  the  tumor.  The 
promptness,  however,  with  which  this  relief  occurs  is  against 
this  supposition,  and  the  further  fact  of  the  frequent  prompt 
relief  of  pain  in  neuralgias  leaves  little  room  for  doubt  that 
the  relief  of  pain  is  to  be  attributed  directly  to  an  intrinsic 
anodyne  quality  of  the  rays. 

Burdick  *  has  reported  a  case  of  osteosarcoma  in  which 
extreme  pain  followed  a  short  time  after  x-ray  exposures,  but 
the  description  of  the  case  does  not  make  it  clear  that  this 
might  not  have  been  due  simply  to  remaining  in  a  cramped 
position  for  several  minutes,  or  some  such  accidental  fact. 
I  have  never  seen  such  an  occurrence.  In  one  case  of  very 
extensive  disease  of  the  scalp  and  face,  which  was  either  tubercu- 
losis of  the  skin  or  blastomycosis,  the  patient  complained  of 
slight  pain  after  x-ray  exposures.  Both  eyes  were  gone  and 
she  was  in  a  highly  nervous  state,  and  we  were  not  able  to 
determine  positively  that  the  increase  of  pain  was  not  due 
to  suggestion,  though  it  seemed  likely  that  the  pain  might 
be  justly  attributable  to  the  x-ray  exposures.  Aside  from  this, 
I  have  never  seen  an  increase  of  pain  after  x-ray  exposures 
in  which  there  was  any  reason  to  believe  that  the  increase 
was  attributable  to  the  x-raj's. 

*  American  Electro-Therapeutic  and  X-Ray  Era,  1001,  i,  Xo.  7,  p.  1. 


CHAPTER  II. 

THE  HISTOLOGICAL  CHANGES  PRODUCED  IN 
TISSUES  BY  X-RAYS. 

STUDIES  of  the  histological  changes  in  the  tissues  produced 
by  x-rays  have  been  made  by  Kibbe,  Gilchrist,  Oudin,  Bar- 
thelemy  and  Darier,  'Behrend,  Unna,  Grouven,  Gassrnann, 
Salamon,  Scholtz,  and  others.  One  of  the  first  studies  is  that 
made  by  Kibbe,*  of  Seattle.  He  excised,  without  local  anes- 
thesia, a  piece  of  skin  one  centimeter  square  from  an  area 
of  deeply  discolored  dry  dermatitis.  "The  histological  changes 
were  as  follows:  The  stratum  corneum  was  apparently  un- 
changed; stratum  lucidum  not  clearly  visible,  excepting  over 
small  areas,  where  the  underlying  disturbance  was  seen  to 
be  slight.  The  outer  layers  of  the  cells  composing  the  rete 
mucosum  presented  the  most  striking  alterations,  particularly 
the  nuclei.  Taking  the  stain  both  with  hematoxylin  and 
lithium  carmin  very  feebly,  the  nuclei  showed  in  addition 
a  peculiar  granular  change,  which  was  first  indicated  in  those 
retaining  a  more  normal  reaction  to  the  stain  by  the  formation 
of  a  fine  nucleolus,  which  could  be  seen  here  and  there  in  the 
process  of  division.  Near  the  stratum  granulosum  the  bodies 
of  the  cells  were  apparently  becoming  converted  into  kerato- 
hyalin  as  a  first  step  to  the  increase  in  bulk,  as  it  were,  of  the 
stratum  granulosum  by  a  development  in  their  interior  of 
coarse  granules,  staining  deeply  with  hematoxylin,  and  also 
with  carmin.  With  the  former  they  appeared  like  blotches 
of  India  ink;  in  some  places  giving  the  impression  as  though 
the  cells  had  been  charred  by  heat.  This  was  particularly 
the  case  around  the  hair  follicles.  The  corium  exhibited  the 
ordinary  changes  found  in  mild  dermatitis:  capillary  dilatation, 
writh  collections  of  round  cells  scattered  through  its  structure, 
particularly  around  the  hair  follicles.  No  extravasations  of 
blood  were  noticed." 

*N.  Y.  MM.  Jour.,  1897,  Ixv,  p.  71. 
249 


250  HISTOLOGICAL    CHANGES    PRODUCED    BY    X-RAYS. 

Gilchrist  *  has  examined  skin  from  dry,  red,  exfoliating  der- 
matitis. "Two  portions  of  skin  were  excised  for  histological 
purposes  on  the  first  day.  One  portion  was  taken  from  the 
dorsal  surface  of  the  phalangeal  region  of  the  third  finger, 
and  the  other  from  the  lateral  margin  of  the  hand  over  the 
base  of  the  metacarpal  of  the  little  finger.  Neither  stained 
nor  unstained  sections  demonstrated  the  presence  of  any  foreign 
particles,  and  only  showed  chronic  inflammatory  changes.  The 
horny  layer  was  thickened  and  half  of  it  was  partially  detached. 
A  large  number  of  brown  pigment  granules  were  found  in  the 
exfoliating  portion.  The  mucous  layer  was  not  thickened, 
but  it  was  more  pigmented  than  normal.  In  the  corium  the 
vessels  were  dilated  and  the  pigment  cells  of  the  papillae  were 
almost  as  numerous  as  are  usually  found  in  a  section  of  negro 
skin.  It  was  suggested  that  particles  of  platinum  might  have 
passed  from  the  tube  through  the  glass  bulb  deep  into  the 
tissues.  Portions  of  exfoliating  skin  were  accordingly  sub- 
mitted to  Professor  Abel  for  chemical  analysis,  and  he  has 
very  kindly  furnished  me  with  the  following  brief  report :  '  I 
could  find  no  platinum  in  the  pieces  of  epidermis  that  you 
left  with  me  for  analysis.'  ' 

Alopecia  in  Guinea-pigs. — Oudin,  Barthelemy,  and  Darier  t 
have  made  a  careful  study  of  skin  taken  from  areas  of  alopecia 
produced  experimentally  in  guinea-pigs  by  x-ray  exposures. 
Their  findings  are  as  follows : 

"The  bulbar  end  of  the  hairs  is  atrophic  and  thin  and  contains 
no  pigment.  The  bulb  is  full  but  very  soft.''| 

"Skin  from  areas  of  alopecia  showed,  first,  an  enormous 
thickening  of  the  epidermis  in  all  its  layers ;  second,  the  atrophy 
of  the  hair  follicles,  which  in  places  had  entirely  disappeared." 

Epidermis. — "The  horny  layer  is  markedly  thickened,  but 
the  individual  cells  have  preserved  their  normal  structures. 

*  Johns  Hopkins  Hosp.  Bull.,  1897,  viii,  p.  17. 

t  Monatshefte  f.  prakt.  Derm.,  1897,  xxv,  p.  417. 

J  Wood  (Lancet,  London,  1900,  i,  p.  231)  has  examined  the  hairs  which  had 
fallen  out  in  alopecia  produced  in  man  by  x-rays.  His  description  is  as  fol- 
lows: "The  shed  hairs  were  brittle  and  pale  in  color,  with  atrophic  bulbs,  while 
microscopically  the  normal  striation  was  indistinct  and  the  medullary  substance 
appeared  to  be  collected  into  separate  nodes  with  clear  intervening  spaces.'' 


HAIR   AND   SEBACEOUS   FOLLICLES.  251 

The  prickle-cell  layer  and  the  palisade  layer  have  also  increased 
in  thickness  enormously;  their  height,  as  shown  by  the  mi- 
crometer, is  ten  to  fifteen  times  as  great  as  normal.  The 
individual  cells  are  larger,  but  especially  they  are  much  more 
numerous,  there  being  ten  or  twelve  rows  of  cells  in  the  Mal- 
pighian  layer,  and  six  to  ten  rows  of  cells  showing  keratohyalin, 
while  in  normal  areas  there  are  only  one,  sometimes  two,  and 
two  to  three  rows  respectively.  The  prickle  cells  are  only 
slightly  changed  in  individual  appearance,  and  as  the  piece 
of  skin  cut  out  was  white,  they  show  very  little  pigment,  and 
those  in  the  first  rows  show  numerous  karyokinetic  figures. 
The  polygonal  cells  show  nothing  abnormal  either  in  proto- 
plasm, nucleus,  or  intercellular  fibers.  The  cells  become  more 
flattened  the  nearer  they  lie  to  the  horny  layer,  and  contain 
kernels  and  balls  of  eleidin  (keratohyalin),  which  increase  in 
number  toward  the  horny  layer,  while  the  cell  nuclei  become 
more  and  more  atrophic.  The  kernels  of  eleidin  become  very 
numerous,  and  of  a  truly  enormous  size.  There  can  be  seen 
often  cells  with  one,  three,  or  four  such  kernels,  as  large  as 
the  nucleus  of  a  Malpighian  cell.  They  are  round  or  irregular 
in  shape,  strongly  refracting,  and  stain  a  bright  red  with  car- 
min." 

Hair  and  Sebaceous  Follicles. — "Normally  the  hair  follicles 
stand  close  to  each  other  in  little  groups,  with  small  glands 
lying  near  them,  and  thin  smooth  muscle;  there  are  eight  or 
ten  hairs  in  each  field  at  the  medium  magnification.  In  the 
affected  skin,  on  the  contrary,  not  a  hair  can  be  seen,  and 
there  remain  only  traces  of  the  follicles;  one,  or  at  most  three, 
in  each  field.  These  are  no  longer  follicles,  but  merely  down- 
ward projections  of  epidermis.  There  is  no  suggestion  of  a 
hair  papilla,  or  of  any  beginning  regeneration.  There  is  nothing 
more  to  be  seen  of  the  sebaceous  glands  or  of  the  muscle.  Sweat- 
glands  are  absent  in  the  normal  skin  in  this  region." 

Cutis. — "  The  changes  in  the  cutis  are  of  a  nature  only  slightly 
in  accord  with  those  in  the  overlying  epidermis.  It  can  be 
noticed  merely  that  the  cells  are  somewhat  more  numerous, 
the  connective-tissue  fibers  have  a  more  parallel  arrangement, 
and  the  elastic  fibers  around  the  hair  follicles  are  wrinkled 


252  HISTOLOGICAL    CHANGES    PRODUCED    BY   X-RAYS. 

and  atrophic.  The  papillae  of  the  cutis  are  higher  and  wider 
in  the  bare  spots  and  in  places  contain  pigment  cells.  The 
connective  tissue  andxelastic  reticulum  of  the  corium  are  normal. 
The  small  vessels  of  the  cutis  and  the  larger  ones  of  the  sub- 
cutis  are  also  normal.  No  changes  in  the  nerve-fibers  could 
be  recognized  in  the  sections. 

"The  destruction  of  the  hair  follicles  and  epidermis,  while 
the  cutis  and  vessels  are  only  in  the  slightest  degree  altered, 
is  very  significant.  The  thickening  of  the  epidermis  in  all 
its  layers,  the  enormous  increase  in  the  keratohyalin,  and  the 
extreme  atrophy  of  the  follicles,  are  to  be  looked  on  as  a  reaction 
against  an  irritation  of  unusual  severity.  This  irritation  seems 
to  increase  the  vitality  of  the  least  differentiated  tissues;  while 
it  produces  degeneration  and  atrophy  of  the  more  highly  differ- 
entiated structures — hairs,  nails,  and  glands.  Whether  this 
atrophy  is  the  result  of  nervous  influence,  of  obliteration  of 
the  vessels,  or  of  circulatory  disturbance,  we  do  not  as  yet 
know." 

Unna  *  has  investigated  the  brownish  pigmented  skin  of 
a  woman  who,  several  weeks  before  death,  had  been  repeatedly 
exposed  to  x-rays.  He  found  increase  of  pigment  in  the  papilla?, 
around  the  vessels,  and  in  the  outer  layers  of  the  cutis,  but 
not  in  the  epidermis.  Numerous  mast  cells  were  present 
around  the  vessels.  The  collagenous  fibers  of  the  cutis  were 
swollen,  and  so  pressed  on  each  other  that  the  lymph-spaces 
were  only  indicated.  The  elastic  fibers  did  not  stain,  as  nor- 
mally, with  acid  orcein,  but  were  otherwise  unchanged.  A 
large  number  of  the  fibers  of  the  cutis  did  not  take  the  normal 
stain  with  the  safranin-water  blue  method,  but  took  a  basic 
red  stain,  showing  that  they  had  become  basophile.  These 
fibers  were  penetrated  by  transverse,  longitudinal,  and  spiral 
crevices,  and  thus  separated  into  irregular  fragments. 

An  extensive  study  has  been  made  by  Scholtz  f  upon  the 
histology  of  tissues  affected  by  x-rays.  It  is  worthy  of  being 
quoted  in  extenso.  In  his  experiments  pigs  were  chosen  for  the 
exposure  because  their  skin  most  closely  resembles  human  skin. 

*Deutsch.  med.  Ztng.,  1898,  xviii,  p.  197. 
fArch.  f.  Derm.  u.  Syph.,  1902,  lix,  p.  241. 


HISTOLOGICAL   CHANGES   IN  THE    SKIN.  253 

Experiment  1. — "A  small  strip  of  skin  on  the  back  of  a 
young  pig  was  exposed  to  the  rr-rays  for  one  hour  at  24  cm. 
distance,  and  after  twenty-four  hours  excised.  No  macroscopic 
changes.  No  definite  microscopic  changes,  except  that  possibly 
the  protoplasm  of  the  prickle  cells  is  slightly  more  diffusely 
and  deeply  stained  than  normal,  and  the  cell  outline  is  not 
quite  so  distinct.  The  protoplasmic  nbrillse  stain  distinctly." 

Experiment  2. — "  Similar  exposure,  excision  after  seven  days. 
Macroscopically  the  hair  is  loosened;  no  other  definite  changes. 
Microscopically:  the  horny  layer  is  somewhat  loosened  and 
showrs  a  few  nucleated  cells.  The  stratum  granulosum  is  only 
intimated,  and  in  some  places  has  entirely  disappeared.  The 
prickle-cell  layer  is  evidently  diminished,  and  the  cells  them- 
selves are  much  altered.  They  are  everywhere  swollen,  their 
outlines  have  disappeared  by  degrees,  and  in  the  palisade 
layer  they  are  pressed  out  into  a  wider  shape.  The  protoplasm 
is  given  a  relatively  more  diffuse  color  with  hematoxylin,  while 
the  nucleus  is  only  slightly  stained  and  its  chromatin  is  divided 
into  little  crumbs.  The  nuclei  are  greatly  swollen  and  often 
angular  and  vacuolated;  the  protoplasm,  and  especially  the 
nuclei,  both  show  vacuoles. 

"  In  almost  every  field  are  cells  with  nuclei  divided  into 
two  or  three  without  mitosis.  Mitoses  are  not  present  at  all, 
or  only  show  a  beginning.  These  evidences  of  degeneration 
are  apparent  everywhere  from  the  palisade  layer  to  the  horny 
layer.  Near  the  external  surface  the  outlines  of  the  cells  are 
hardly  visible,  and  their  protoplasm  has  blended  into  a  homo- 
geneous mass.  The  nuclei  are  for  the  most  part  shadows. 
In  the  hair  follicles  and  sheaths  the  changes  in  the  cells  are 
entirely  analogous;  and  the  loosening  and  falling  of  the  hairs 
is  easy  to  understand  in  the  light  of  this  cell  degeneration. 

"The  corium  is  cedematous;  the  connective-tissue  fibers  do 
not  stain  well,  are  somewhat  swollen,  and  homogeneous.  The 
'basophile  reaction'  which  Unna  mentions  is  not,  however, 
found.  The  elastic  reticulum  is  still  present.  No  change  is 
apparent  in  the  small  vessels.  Evidences  of  inflammation  are 
only  intimated.  The  connective-tissue  cells  show  changes  in 
a  slight  degree.  They  have  a  clear  protoplasm,  more  or  less 


254  HISTOLOGICAL    CHANGES    PRODUCED    BY    X-RAYS. 

diffusely  stained,  are  swollen  and  often  of  peculiar  shape.  The 
cells  of  the  sweat-glands  also  show  a  similar  slight  degenerative 
change,  with  occasional  proliferation,  and  have  here  and  there 
dropped  out  into  the  gland  lumen.  In  the  larger  vessels  there 
is  present  in  the  media,  and  especially  in  the  intima,  slight 
cell  degeneration,  altogether  analogous  to  that  seen  elsewhere. 
The  cells  of  the  intima  are  swollen,  project  into  the  lumina 
of  the  vessels,  in  some  places  show  evident  proliferation,  with 
a  tendency  to  fall  off  into  the  blood-current." 

Experiment  3. — "  Back  of  a  young  pig  exposed  daily  for 
nine  days,  fifteen  minutes  each,  at  a  distance  of  15  cm.  Ex- 
cision twenty-four  hours  after  last  exposure.  Macroscopically : 
hair  beginning  to  fall  out,  slight  appearance  of  atrophy  and 
redness  of  skin.  Histologically :  changes  throughout  analogous 
to  those  in  Experiment  2,  but  more  decided ;  in  addition,  begin- 
ning inflammatory  reaction.  In  the  corium,  especially  around 
the  vessels,  there  is  a  slight  infiltration  with  round  cells  and 
single  polymorphonuclear  cells;  and  a  few  of  these  are  also 
already  present  in  the  rete.  The  smaller  vessels,  especially 
of  the  papillae,  seem  to  be  somewhat  dilated." 

Experiment  4. — "The  ear  of  a  pig  was  exposed  eleven  times 
for  fifteen  minutes  each  at  a  distance  of  15  cm.  Six  days 
after  last  exposure  a  triangular  piece  was  cut  out  of  the  edge 
of  the  ear.  Macroscopically:  hair  fallen  out  on  both  surfaces, 
skin  reddened,  with  an  atrophic  appearance;  on  the  outside, 
especially  near  the  middle  of  the  ear,  slight  raising  of  the  epithe- 
lium in  blisters.  Microscopically :  degenerative  changes  of  the 
cellular  elements  similar  to,  but  more  marked  than,  those 
of  Experiments  2  and  3.  Diminution  in  thickness  and  homo- 
geneity of  the  epithelium  more  marked,  active  inflammatory 
reaction,  with  thick  infiltration  with  polymorphonuclear  leuco- 
cytes. Masses  of  leucocytes  are  passing  toward  the  epithelium ; 
some  have  pushed  between  and  in  the  degenerated  epithelial 
cells,  so  that  one  gets  the  impression  that  here  the  leucocytes 
are  playing  a  truly  phagocytic  role.  Below  the  infiltrating 
cells  are  numerous  heavily  loaded  mast  cells.  Toward  the 
center  of  the  exposed  area  the  horny  layer,  alone  or  with  the 
few  remains  of  the  rete,  is  raised  in  blisters,  with  thick  masses 


HISTOLOGICAL    CHANGES    IN    THE    SKIN.  255 

of  leucocytes  under  it ;  and  in  the  more  strongly  affected  places 
the  horny  layer  is  completely  lacking,  and  here  are  the  first 
beginnings  of  the  so-called  x-ray  ulcer.  The  elastic  reticulum 
is  more  poorly  stained,  but  is  still  intact.  The  changes  in  the 
connective  tissue  resemble  those  in  Experiment  2.  The  cartilage 
of  the  ear  is  unaltered.  In  the  large  vessels  the  cells  of  the 
intima  and  media  are  greatly  changed;  they  appear  swollen, 
the  protoplasm  diffusely  stained,  the  nuclei  pale,  and  the 
chromatin  in  crumbs.  Two,  three,  and  four  nuclei  are  often 
to  be  seen  in  one  cell  as  the  result  of  amitotic  splitting  of  the 
nucleus  without  cell  division.  Protoplasm  and  nuclei  show 
general  vacuolization,  and  here  and  there  large  vacuoles  are 
apparent.  The  swollen  cells  of  the  intima  float  detached  in 
the  lumina  of  the  smaller  vessels.  The  lumina  are  otherwise 
still  intact,  and  filled  partly  with  blood-corpuscles,  partly 
with  an  uncolored  thready  mass  of  particles,  in  which  bands 
of  fibrin  are  only  exceptionally  visible.  The  cells  of  the  sweat- 
glands  are  also  markedly  degenerated  and  vacuolated,  the 
lumina  being  partly  filled  with  leucocytes. 

' '  Where  the  rete  projects  down  into  the  cutis  as  the  outer 
sheath  of  the  hair  follicles,  similar  degenerative  processes 
are  to  be  seen  in  the  cells,  and  the  same  inflammatory  reaction 
is  present  as  above.  The  hair  follicles  are  almost  completely 
destroyed,  and  in  their  places  are  collections  of  leucocytes." 

Experiment  5. — "Skin  of  back  of  pig  exposed  9  times,  fifteen 
minutes  each,  at  15  cm.  Excised  eight  days  after  last  ex- 
posure. Macroscopically :  Rdntgen  ulcer.  Exposed  portion  of 
skin,  which  began  to  get  moist  four  days  after  last  exposure, 
is  now  superficially  necrotic  and  covered  with  a  thin  fibrino- 
purulent  exudate.  The  area  has  the  appearance  of  a  purulent 
burn  of  the  second  degree.  Microscopically:  the  changes  re- 
semble those  in  the  beginning  of  x-ray  ulcer,  described  in 
Experiment  4,  showing  a  more  severe  degree.  There  exists 
now  no  trace  of  the  rete  Malpighii  or  of  the  horny  layer;  in 
place  of  them  is  a  thick  layer  of  well-formed  leucocytes,  poly- 
nuclear  predominating.  These  pus  cells  lie  close  to  each  other, 
interpenetrated  by  a  fine  fibrillar  material  which  is  the  only 
fibrin  revealed  by  Weigert's  stain.  Above  this  layer  of  leuco- 


256  HISTOLOGICAL    CHANGES    PRODUCED    BY    X-RAYS. 

cytes  there  exists  a  thin  layer  composed  of  pus  cells,  detritus, 
remnants  of  nuclei,  and,  most  numerous,  bacilli  and  cocci, 
which  therefore  stains  by  Gram  almost  uniformly  a  dark  violet. 
The  x-ray  ulcer  is  thus  composed  of  masses  of  leucocytes, 
remains  of  cell  protoplasm  and  nuclei,  and  bacteria.  This  is 
sharply  defined  toward  the  corium  in  some  places,  while  in 
others  it  shades  off  into  a  zone  of  connective  tissue  infiltrated 
with  pus  cells. 

"The  papillae  are  for  the  most  part  still  normal  in  outline, 
or  at  least  recognizable.  The  connective-tissue  fibers,  just 
under  the  ulcer  especially,  are  soaked  in  serum  and  in  places 
are  split  up  into  very  fine  fibrilke.  The  elastic  reticulum  is 
still  present  in  its  entirety.  The  connective-tissue  cells  show, 
as  in  Experiment  2,  degenerative  processes  to  a  pronounced 
extent.  Their  protoplasm  is  usually  swollen  and  stains  dif- 
fusely with  hematoxylin,  and  the  single  or  multiple  nuclei 
are  also  swollen,  the  cells  presenting  various  curious  shapes. 

"The  larger  vessels  show  still  more  marked  degeneration, 
especially  of  the  cells  of  the  intima  and  media,  proliferation 
and  falling-off  of  the  intima  cells,  and  vacuolation  of  the  walls, 
as  described  by  Gassman  and  Lion.  The  smaller  vessels  are 
greatly  dilated,  filled  with  blood,  and  surrounded  by  a  wall 
of  leucocytes. 

"In  the  cutis  and  layer  of  leucocytes  are  large  and  small 
hemorrhages.  Changes  in  the  glands  are  similar  to  those  in 
Experiment  4.  The  hair  roots  are  entirely  destroyed,  and 
in  their  places  are  collections  of  leucocytes,  among  which  some 
remains  of  nuclei  and  unstained  fibrinous  material  can  be 
distinguished.  Wherever  the  rete  normally  has  sent  processes 
into  the  corium  are  now  present  extensions  of  the  ulcerative 
process." 

Experiment  6. — "The  histological  findings  in  the  later  stages 
of  more  severe  x-ray  ulcers,  as  I  have  determined  them  in 
three  other  examinations,  can  be  summed  up  as  follows:  The 
changes  in  the  more  superficial  layers  correspond  throughout 
to  those  in  Experiment  5,  but  the  detritus,  remains  of  cells 
and  nuclei,  and  bacteria  are  greater  in  amount,  while  the 
normal  leucocytes  are  less  numerous.  The  degenerative  pro- 


HISTOLOGICAL    CHANGES    IN   THE    SKIN.  257 

cesses  still  affect  both  the  cellular  and  intercellular  elements 
of  the  cutis;  the  cells  have  taken  on  an  appearance  of  giant 
cells,  and  the  fibers  of  the  connective  tissue  are  for  the  most 
part  dissolved  into  thin  fibrillar  material,  which  still  reacts 
to  the  fibrous  tissue  stain.  The  connective  tissue  has  in  general 
a  vacuolated  appearance,  and  is  more  or  less  infiltrated  with 
round  cells  and  pus  cells.  The  glands  are  entirely  obliterated, 
and  the  larger  vessels  in  places  completely  destroyed.  The 
dilatation  of  the  smaller  vessels,  the  stasis  of  blood  in  them, 
and  the  hemorrhages  are  increased,  and  their  walls  in  places 
have  degenerated  into  homogeneous  masses.  Deeper  in  the 
corium  the  tissues  are  altogether  normal." 

Experiment  7. — "In  various  stages  of  reaction  after  exposures 
in  various  degrees  of  severity  of  human  skin,  I  was  able  to 
demonstrate  that  the  x-ray  changes  are  entirely  similar  to 
those  in  the  skin  of  the  pig.  Slight  exposures  lead  to  degenera- 
tive processes  similar  to  those  described,  especially  in  the  hair 
follicles.  In  general,  a  more  marked  vacuolation,  especially 
in  the  palisade  layer,  is  apparent  in  human  than  in  pig  skin, 
though  the  reason  may  have  been  in  a  difference  in  the  method 
of  exposure.  Also,  pigment  was  to  be  found  not  only  in  the 
deep  layers  of  the  rete,  but  also  in  the  outer  part  of  the  corium. 
This  strong  over-pigmentation  seems  to  take  place  especially 
in  treatment  of  psoriasis ;  at  least  we  have  seen  its  appearance 
almost  always  both  in  the  healing  psoriatic  areas  and  in  the 
healthy  surrounding  skin,  while  in  other  disease  it  is  a  phe- 
nomenon of  merely  occasional  occurrence.  The  changes  of 
higher  degree  in  human  skin  so  entirely  resemble  those  in  the 
pig  skin  that  they  need  no  further  description." 

Experiment  8. — "The  process  of  healing  of  superficial  x-ray 
ulceration  and  excoriation  I  was  able  to  study  in  human  skin, 
and  of  course  in  lupous  tissue.  The  infiltration  in  the  corium 
vanishes,  the  cells  and  nuclei  of  the  connective  tissue  become 
again  normal,  and  where  the  papilla?  have  been  destroyed 
there  commences  a  formation  of  fine,  horizontal  connective- 
tissue  fibrillse.  The  epithelium  grows  forward  from  the  edges, 
sending  processes  into  the  still  soft  and  cedematous  connective 
tissue,  or  stretching  over  the  papilla?  which  remain.  In  this 

17 


258  HISTOLOGICAL   CHANGES   PRODUCED    BY   X-RAYS. 

case  the  normal  appearance  of  the  skin  is  renewed,  only  the 
destroyed  follicles  being  lacking.  Both  the  connective  tissue 
and  the  epithelium  in  the  healed  areas  remain  soft  and  tender, 
the  latter  showing  grave  disturbances  for  some  time.  The  cells 
of  the  rete  remain  oedematous,  the  prickle  cells  swollen,  vacuo- 
lated,  with  swollen  and  poorly  stained  nuclei.  The  prickle-cell 
layer  and  the  horny  layer  are  often  much  thickened,  and  the 
keratohyalin  in  the  cells  is  distributed  in  irregular  clumps 
and  crumbs.  In  the  horny  layer  are  nucleated  cells  not 
completely  cornified.  I  have  noticed,  however,  in  cases  in 
which  the  process  has  resulted  not  in  ulceration,  but  merely 
in  a  rather  severe  dermatitis,  similar  appearances  in  these 
layers  some  weeks  after  the  cessation  of  exposures.  Thus  it 
is  easy  to  understand  why  fresh  x-ray  scars  and  strongly  exposed 
areas  of  the  skin  are  extremely  sensitive  both  to  caustics  and 
to  x-rays  themselves,  and,  for  instance,  how  the  application  of 
pyrogallic  salve  quickly  causes  renewed  ulceration,  which  then 
heals  very  slowly.  We  had  occasion  to  see  three  typical  in- 
stances of  this." 

"The  following  conclusions  may  be  drawn  from  my  histo- 
logical  observations : 

I.  "X-rays  influence  especially  or  exclusively  the  cellular 
elements  of  the  skin.  These  are  influenced  primarily,  and 
undergo  a  slow  degeneration,  while  the  connective  tissue, 
the  elastic  tissue,  musculature,  and  cartilage  are  changed  only 
in  a  slight  degree,  and  suffer  only  secondarily,  as  a  result  of 
the  cellular  degeneration  and  the  inflammatory  reaction  conse- 
quent to  it." 

II.  "The  degeneration  affects  the  epithelial  cells  in  the 
highest  degree,  and  to  a  less  extent  the  cells  of  the  glands, 
the  vessels,  the  muscular  tissue,  and  the  connective  tissue." 

III.  "The  degenerative  appearances  are  of  various  kinds,  and 
affect  both  the  protoplasm  and  nuclei." 

IV.  "As  soon  as  the  degeneration  of  the  cells  has  reached 
a    certain    point,    an    inflammatory    reaction    appears,    which 
manifests  itself  in  a  marked  dilatation  of  the  vessels,   with 
gathering   leucocytes    and   marked   emigration    of   the   blood- 


MICROSCOPIC  CHANGES  IN  PSORIASIS  UNDER  X-RAYS.        259 

corpuscles.  When  greater  cell  degeneration  occurs  as  a  result 
of  stronger  exposure,  collections  of  leucocytes  press  into  a 
mass  of  degenerated  cells  and  accomplish  their  further  de- 
struction." 

V.  "The  changes  in  the  large  and  small  vessels  are  apparently 
of  great  importance  as  affects  the  further  development  and 
slow  healing  of  the  ulcerations." 

Gassmann  *  has  examined  tissues  from  the  border  of  x-ray 
ulcers.  The  changes  that  he  finds  in  the  tissues  are  practically 
the  same  as  those  already  described.  He  gives  an  accurate 
description  of  the  changes  in  the  blood-vessels  as  follows : 

"  Important  changes  are  noticeable  in  the  vessels.  The  walls 
of  the  small  vessels  and  capillaries  in  the  upper  zone  of  the  ulcer 
are  changed  into  irregular  swollen  masses,  the  lumen  being 
sometimes  entirely  obliterated  and  sometimes  filled  with  cor- 
puscles, in  which  latter  case  the  vessel  is  surrounded  by  a  col- 
lection of  infiltrating  cells.  The  intima  is  thickened  and  the 
endothelial  cells  are  swollen,  and  often  detached  from  the  wall. 
The  small  vessels  of  the  deeper  tissues  show  similar  changes 
of  the  intima,  the  lumen  often  being  entirely  or  partly  obliter- 
ated. In  the  larger  arteries  and  veins  of  the  subcutis  the  intima 
is  thickened,  there  is  proliferation  of  the  endothelial  cells, 
filling  perhaps  half  of  the  lumen.  The  intima  shows  numerous 
vacuoles  and  crevices.  The  muscular  layer  also  shows  vacuoles; 
the  cells  seem  to  be  pressed  together,  are  smaller,  and  the 
fibers  between  them  do  not  stain  well.  Leucocytes  are  present 
in  the  media,  and  more  numerously  in  the  adventitia.  Neither 
the  inner  nor  outer  elastic  layers  are  compact,  but  both  are 
loose,  the  fibers  separated  from  each  other  by  spaces  and  in- 
creased in  number.  Not  all,  but  many,  of  the  large  vessels 
show  these  changes.  The  lumina  are  sometimes  empty  though 
not  obliterated,  sometimes  filled  with  blood." 

Microscopic  Changes  in  Psoriasis  under  X-rays. — Scholtz  f 
givos  the  following  description  of  a  study  of  psoriasis : 

"An  area  of  psoriasis  was  exposed  from  May  31  to  June  6 
five  times,  ten  minutes  each,  at  40  cm.  distance.  June  8  the 

*  Fortschr.  a.  d.  Geb.  cl.  Rontgenstrahlen,  1899,  ii,  p.  199. 
f  Arch.  f.  Derm.  n.  Syph.,  1902,  lix,  p.  241. 


260  HI6TOLOGICAL    CHANGES    PRODUCED    BY   X-RAYS- 

scales  were  completely  fallen  off  and  the  psoriatic  area  was 
already  completely  smooth  and  colored  with  dark  brown  pig- 
ment. The  healthy  skin  in  the  vicinity  was  also  slightly 
colored.  At  this  time  a  piece  was  excised  containing  both 
healthy  and  psoriatic  tissue. 

"Microscopically  the  typical  alterations  of  psoriasis  were 
almost  entirely  vanished.  Only  the  prickle-cell  layer  and 
stratum  granulosum  in  the  diseased  area  were  still  somewhat 
thickened,  and  there  was  some  infiltration  of  the  papilla?  and 
around  the  subpapillary  vessels  of  the  corium.  The  epithelial 
cells  themselves  again  showed  the  usual  changes.  The  healthy 
as  well  as  the  diseased  tissues  were  peculiarly  pigmented. 
In  one  place  in  the  corium,  especially  in  the  papillae  and  near 
the  palisade  layer,  were  cells,  some  long,  some  star-shaped, 
with  irregular  nuclei,  whose  protoplasm  was  stuffed  full  of 
round,  large,  yellowish-brown  particles  of  pigment.  Also  there 
were  in  the  rete  Malpighii  several  similar  cells  (leucocytes) 
between  the  epithelial  cells.  Moreover,  the  cells  of  the  rete, 
especially  in  the  deeper  layers,  contained  in  their  protoplasm 
fine  particles  of  the  same  color,  and  a  fine  network  of  particles 
of  pigment  lying  close  to  each  other,  seemed  to  be  interwoven 
around  these  cells.  Closer  examination  leads  me  to  believe 
that  we  have  here  to  do  not  with  intercellular  pigment,  but 
with  particles  deposited  in  the  edges  of  the  epithelial  cells 
themselves,  in  their  protoplasmic  fibrils.  In  favor  of  this  view 
are  the  club-shaped  projections  toward  the  corium,  and  the 
observation  that  the  protoplasmic  fibrils  in  the  areas  rich 
in  pigment  do  not  stain  well,  as  has  been  described  by  Kro- 
maj^er.  It  will,  however,  require  further  research  to  determine 
this  point.  This  pigment  gave  no  reaction  for  iron  with  sodium 
ferrocyanide  and  HC1." 

Microscopic  Changes  in  Lupous  Tissue. — Scholtz's*  study  is 
as  follows : 

I.  "Rather  deep  lupous  area  on  breast,  which  is  deeply 
infiltrated,  thickly  set  with  tubercles,  and  covered  with  a  thin 
crust.  -X-ray  treatment  February  8  to  March  7  at  intervals, 
in  all  ten  exposures,  eight  to  ten  minutes,  at  35  cm.  distance. 

*Arch.  f.  Derm.  u.  Syph.,  1902,  lix,  p.  241. 


MICROSCOPIC   CHANGES   IN    LUPOUS   TISSUE.  261 

After  a  few  weeks  a  severe  dermatitis  of  the  exposed  surface 
appeared,  with  subsequent  superficial  necrosis  of  the  area. 
Excision  March  17.  The  area  has  been  for  about  eight  days 
decidedly  reddened  and  somewhat  swollen,  with  the  epithelium 
raised  in  blisters  in  the  middle.  A  piece  cut  from  the  edge 
wras  hardened  in  alcohol  and  Fleming  solution.  Microscopic 
examination  shows  the  epithelium  in  a  degenerated  homo- 
geneous condition,  mostly  raised  in  blisters.  The  cutis,  espe- 
cially in  the  lupous  area,  is  thickly  infiltrated  with  round  cells 
and  pus  cells.  The  form  and  typical  structure  of  the  tubercles 
have  disappeared,  and  the  tubercles  are  to  a  certain  extent 
absorbed.  In  their  place  are  collections  of  numerous  abnormally 
large  giant  cells,  single  and  multiple  nucleated  cells  with  swollen, 
washed-out  protoplasm  (altered  epithelioid  cells),  and  among 
them  mononuclear  and  especially  polymorphonuclear  leucocytes 
in  great  numbers.  The  giant  cells  contain  an  unusually  large 
number  of  nuclei,  and  measure  100  to  200  microns  in  diameter. 
Most  of  them  no  longer  show  regular  outlines;  there  is  pre- 
sented a  pale  irregular  mass  of  protoplasm  containing  a  great 
number  of  nuclei,  and  mingling  diffusely  with  the  surrounding 
tissue.  The  altered  epithelioid  cells,  which  are  often  poly- 
nuclear,  show  the  same  appearances. " 

II.  "  Excision  on  March  25.     The  area  is  superficially  necrotic, 
and  covered  with  a  thin  fibrino-purulent  exudate.     Microscopic 
examination:  Superficial   crust   similar   to   that   described   on 
the  normal  skin.     The   changes  in  the  lupous  tubercles  are 
similar  to  those  given  above,  but  still  more  pronounced.     The 
destruction  and  absorption  of  the  tubercles,  their  penetration 
by  round  cells  and  pus  cells,  and  the  degeneration  of  the  epithe- 
lioid and  giant  cells  have  made  further  progress.     Here  also 
the  leucocytes  seem  to  be  taking  an  active  part  in  the  complete 
destruction  of  the  degenerated  cells. " 

III.  "A  similar  area  after  subsequent  covering  with  skin. 
A  piece  of  the  border  which  showed  some  suspected  lumps, 
while  the  rest  of  the  area  was  free,  was  chosen  for  excision. 
Microscopic    examination    showed    the    epithelium    stretched 
out  smooth  over  the  corium,  with  no  projections  into  it,  in 
three  or  four  layers  of  cells.     Its  cells  still  show  changes.     The 


262  HISTOLOGICAL    CHANGES    PRODUCED    BY   X-RAYS. 

corium  is  almost  free  from  accumulations  of  cells.  The  con- 
nective tissue  is  composed  of  fine,  thin,  but  well-stained  fibers, 
which  for  the  most  part  run  parallel  to  the  epithelium,  and 
only  to  a  slight  extent  transversely.  In  certain  places  are 
still  apparent  some  remains  of  tubercles,  principally  in  the 
form  of  bunches  of  protoplasm  with  numerous  nuclei.  Some 
of  these  are  still  penetrated  and  surrounded  by  leucocytes, 
others  are  circumscribed  and  encapsulated  by  fibrils  of  new 
connective  tissue,  some  of  which  cross  through  them." 

IV.  "Lupus  of  the  cheek  and  nose;  cheek  infiltrated,  showing 
numerous  lupous  tubercles.  X-ray  treatment  from  February  27 
to  March  7,  with  one  interruption,  in  all  seven  exposures,  of 
five  to  ten  minutes,  at  a  distance  of  10  cm.  to  35  cm.  By 
the  middle  of  March  the  area  is  very  red  and  somewhat  swollen, 
but  with  no  ulceration  on  the  cheek.  April  1,  the  inflammatory 
appearances  are  entirely  vanished.  The  tubercles  are  not  so 
numerous  and  not  so  apparent  as  before,  but  there  can  always 
be  recognized  on  pressure  with  a  glass  quite  a  number  of  small 
typical  or  suspicious  tubercles.  Excision  of  one  such  from 
the  middle  of  the  area.  Microscopic  examination  shows  appear- 
ance of  degeneration  already  marked  in  the  epithelial  cells, 
but  regeneration  has  already  begun,  the  Malpighian  layer  being 
especially  thickened.  In  the  tubercles  are  seen  changes  similar 
to  those  in  (I),  but  not  so  marked.  The  tubercles  are  still 
typical  in  shape  and  structure;  the  changes  in  the  giant  cells 
and  epithelioid  cells  less  evident,  but  still  clear.  Around  the 
tubercles  exists  already  a  definite  wall  of  mononuclear  and 
polynuclear  leucocytes,  and  they  are  also  already  penetrated  by 
leucocytes,  but  the  infiltration  is  not  so  far  advanced  as  in  (I). 

"Thus  the  action  of  the  rays  on  lupous  tissue  is  entirely 
similar  to  that  on  the  normal  skin:  First,  degenerative  processes 
in  the  cellular  elements  and  epithelioid  cells  of  the  lupous 
tubercles  themselves;  which  are  followed  by  the  appearance 
of  an  inflammatory  reaction. 

"The  healing  of  the  lupus  and  the  destruction  of  the  bacilli 
result  thus  from  the  reactive  hyperemia  and  inflammation, 
and  we  can  draw  no  deduction  as  to  any  bactericidal  properties 
of  the  x-rays.  The  principal  peculiar  important  effect  of  or-rays 


CHANGES   IN   LEPROUS  TISSUE.  263 

in  the  treatment  of  lupus  lies  in  the  reactive  inflammation 
concentrated  upon  the  affected  spot,  which  results  from  the 
degenerative  processes  induced  in  the  tubercles.  The  reaction 
to  the  x-rays  is  similar  to  that  induced  by  tuberculin,  except 
that  it  extends  over  a  long  period  of  time." 

Grouven  *  has  studied  sections  from  lupus  of  the  cheek, 
treated  ten  weeks  by  x-rays.  They  show  a  large  formation 
of  connective-tissue  fibers  surrounding  and  encapsulating  the 
tubercles  and  running  through  them,  with  numerous  spindle 
cells  and  evidences  of  new  formation.  The  epithelioid  cells 
and  lymphocytes  of  the  lupous  tubercles  show  vacuolization 
and  loss  of  staining  reaction,  and  degeneration  of  both  nucleus 
and  protoplasm.  He  describes  the  course  of  healing  of  lupus 
as  follows :  Hyperemia,  leading  to  increased  diapedesis  of  leuco- 
cytes, first  at  periphery  of  nodules,  pressing  on  into  interior, 
changing  into  spindle  cells  and  new  connective-tissue  elements. 
The  cells  of  the  nodules  undergo  degeneration  and  absorption, 
and  are  replaced  by  connective  tissue. 

Lepra. — Scholtz  f  examined  tissue  from  the  middle  of  a 
nodule  of  lepra  which  had  been  exposed  to  x-rays  until  redness 
had  appeared.  "Some  time  after  the  disappearance  of  this 
reaction  the  part  of  the  nodule  which  had  been  treated  seemed 
to  be  a  little  sunken,  but  no  further  change  appeared.  Five 
weeks  later  the  nodule  was  excised. 

"Microscopically,  the  leprous  infiltration  in  the  exposed 
region  was  slightly  reduced.  The  numerous  bacilli  seemed  to 
show  more  granulation  than  in  the  unexposed  region,  but  were 
well  stained  and  undiminished  in  number,  the  action  of  the 
rays  having  on  them  no  apparent  influence." 

The  changes  here,  therefore,  are  without  significance.  This 
fact  probably  means  nothing,  because  the  exposures  were  not 
carried  far  enough  to  produce  effect.  Theoretically,  there 
seems  no  reason  why  an  individual  nodule  of  lepra  should 
not  be  affected  in  the  same  way  as  a  nodule  of  tuberculosis. 

Changes  in  Carcinomatous  Tissue  under  X-rays. — Scholtz  f 
reports  upon  his  study  of  carcinoma  as  follows:  "In  one  case 

*  Fortschr.  a.  d.  Geb.  d.  Rontgenstrahlen,  1902,  v,  p.  186. 

t  Arch.  f.  Derm.  u.  Syph.,  1902,  lix,  p.  241.  J  Loc.  cit. 


264  HISTOLOGICAL    CHANGES    PRODUCED    BY    X-RAYS. 

of  carcinoma  I  was  able  to  obtain  excisions  in  the  stage  of 
beginning  reaction,  and  also  after  the  formation  of  a  superficial 
necrosis. 

"On  the  whole,  the  microscopic  examination  of  the  pieces 
of  carcinomatous  tissue  showed  that  under  the  influence  of 
the  x-rays  the  cancer  cells  degenerate  and  are  destroyed,  just 
as  the  normal  epithelial  cells.  However,  the  degenerative  pro- 
cesses are  recognizable,  especially  in  the  deeper  carcinoma 
points,  only  after  a  relatively  more  intense  action  of  the  rays ; 
and  the  appearances  were  often  difficult  to  distinguish  from 
the  normal  retrogressive  processes.  In  one  case,  excision  after 
eight  exposures  of  ten  minutes  each,  at  20  cm.,  fixation  in 
Fleming,  and  staining  with  safranin,  numerous  beginning 
mitoses  were  apparent  in  every  field,  but  nowhere  could  be 
seen  the  normal  course  of  mitotic  division.  The  cells  mentioned 
were  filled  with  intensely  stained  fibrils  and  bunches  of  chro- 
matin,  irregularly  distributed  and  of  varying  thickness,  but  no 
division  occurred;  the  chromatin  seemed  to  reunite  into  single 
rings  and  bunches." 

I  have  examined  tissue  taken  from  carcinomata  in  various 
stages  of  subsidence  under  the  influence  of  x-rays.  The  findings 
in  all  have  been  practically  identical.  The  following  case 
presents  accurately  the  histological  conditions  found  in  all 
the  cases  examined:  On  December  5,  1901,  a  piece  of  tissue  was 
excised  from  the  border  of  a  carcinoma  ulcer  on  the  cheek 
(see  Case  53,  Fig.  127).  This  case  had  had  ten  x-ray  exposures, 
and  at  the  time  was  just  beginning  to  show  the  first  trace  of 
irritation.  Its  nodular  character  had  not  been  altered.  The 
first  indications  of  effect  on  the  growth  were  just  appearing. 
The  tissue  was  put  through  4  per  cent,  formalin  and  alcohol, 
imbedded  in  celloidin  in  the  usual  way,  and  stained  with  hema- 
toxylin  and  eosin.  The  notes  *  of  the  examination  are  as 
follows:  The  tumor  is  composed  of  epithelial  cells,  arranged 
in  more  or  less  circular,  oval,  and  narrow  groups,  in  glandular 

*The  notes  of  this  case  are  condensed  from  notes  made  toy  Mr.  E.  H.  Ruodi- 
ger,  to  whom  I  am  indebted  for  valuable  aid  in  this  work.  It  is  due  Mr.  Kuedi- 
ger  to  say  that  this  description  was  written  without  any  knowledge  of  the  ob- 
servations, which  are  so  strikingly  similar,  made  by  other  observers. 


CHANGES   IN   CARCINOMATOUS   TISSUE   UNDER   X-RAYS.     265 

and  tubular  form,  and  these  islands  of  tumor  cells  are  sur- 
rounded by  fibrous  tissue  stroma  (Fig.  93).  Diagnosis,  glandular 
carcinoma  of  the  skin.  Blood-vessels  are  found  in  various 
parts  of  the  stroma,  but  none  are  seen  in  the  islands  of  tumor 
cells.  At  the  periphery  of  the  islands,  where  evidently  the 
growth  of  the  tumor  has  been  most  pronounced,  and  the  youngest 
tumor  cells  exist,  there  is  a  peculiar  breaking-down  and  dis- 
appearance of  the  cells.  The  outline  of  cells  here  is  vague 
or  lacking.  The  nuclei  are  fragmented  and  the  fragments 
scattered,  or  at  least  spread  apart,  leaving  merely  dim,  shapeless 
remnants  that  take  a  pale  blue  stain.  In  some  of  the  blood- 
vessels, especially  those  intimately  connected  with  the  tumor 
tissue,  which  make  themselves  quite  prominent  by  areas  of 
broken-down  tumor  cells  surrounding  them,  there  is  an  extreme 
degree  of  endarteritis,  almost  or  entirely  obliterating  the  lumina. 
Other  blood-vessels  lying  more  distant  from  the  islands  of 
tumor  cells  show  no  such  change. 

On  February  8,  1902,  or  about  two  months  after  the  first 
tissue  was  taken,  a  second  piece  was  excised  from  relatively 
the  same  point  in  the  border  of  this  ulcer.  At  the  time  the 
border  of  the  ulcer  had  flattened  down  completely,  and  had 
entirely  lost  its  nodular  character.  The  notes  of  examination 
of  this  specimen  are  as  follows:  Microscopic  examination  now 
shows  scarcely  a  trace  of  tumor  left  (Figs.  94  and  95).  Beneath 
the  epidermis  there  is  a  considerable  layer  of  fibrous  tissue 
in  which  there  are  areas  staining  pale  blue  with  hematoxylin 
similar  to  the  blue  material  found  at  the  periphery  of  the  islands 
of  tumor  cells  described  in  the  tissue  excised  December  5. 
There  are  seen  occasionally,  also,  some  granules  which  appear 
to  be  fragments  of  nuclei.  The  areas  which  have  been  occupied 
by  tumor  tissue  are  now  being  filled  by  connective  tissue. 
The  normal  tissue  shows  nothing  unusual.  There  are  sweat- 
glands  and  muscle-fibers,  having  the  same  appearance  as  in 
healthy  and  untreated  tissue,  and  the  surrounding  blood- 
vessels show  no  such  endarteritis  as  is  described  in  the  tissue 
examined  two  months  ago. 

In  other  words,  in  this  case  there  was  a  sufficient  reaction 
to  destroy  the  highly  susceptible  carcinoma  cells,  while  the 


268  HISTOLOGICAL    CHANGES    PRODUCED    BY    X-RAYS. 

surrounding  healthy  tissue  was  much  less  affected  and  was 
already  regaining  its  normal  condition. 

In  one  of  my  cases  of  carcinoma  of  the  breast  in  which  the 
breast  was  obtained  after  death,  histological  changes  corre- 
sponding in  all  essential  respects  with  the  above  were  found 
well  down  in  the  substance  of  the  breast  by  Prof.  W.  A.  Evans, 
of  the  University  of  Illinois,  so  that  there  is  no  doubt  that 
these  changes  can  be  produced  beneath  unbroken  healthy  tissue. 

Considering  the  tissue  excised  at  different  times,  the  salient 
features  found  in  the  histological  examination  are  these: 

The  first  changes  occur  in  the  cells  at  the  periphery  of  each 
nest  of  carcinoma.  Later  the  same  process  involves  all  of 
the  mass,  invading  in  succession  the  cells  from  the  periphenT 
to  the  center.  These  cells  are  found  in  various  stages  of  de- 
struction, or,  if  such  it  may  be  called,  necrosis.  The  term 
necrosis,  however,  as  ordinarily  used,  does  not  accurately 
describe  the  process  as  it  occurs  under  x-rays.  In  the  ordinary 
form  of  necrosis  the  cells  retain  more  or  less  completely  their 
form,  and  the  first  change  noticed  is  in  the  nuclei,  which  fail 
to  take  the  basic  stain,  while  the  tissue  in  general  takes  a 
diffuse  acid  and  basic  stain,  apparently  a  mixture  of  the  two. 
On  the  other  hand,  in  the  tissue  breaking  down  under  x-rays 
the  cells  and  nuclei  lose  their  outline;  the  chromatin  of  the 
nuclei  appears  to  become  spread  out  and  mixed  with  proto- 
plasm of  the  cells,  where  it  is  frequently  seen  as  streaks  or 
more  or  less  irregular  areas  staining  a  rather  bright  blue  and 
resembling  to  a  certain  extent  mucoid  degeneration. 

The  blood-vessels,  especially  the  small  ones  which  are  in 
close  relation  to  the  tumor,  show  marked  endarteritis,  com- 
pletely occluding  the  lumina  of  the  vessels.  Around  the 
occluded  blood-vessels  the  breaking-down  of  tumor  cells  is 
decidedly  more  pronounced  than  at  any  other  place,  even  at 
the  periphery  of  the  cell  nests.  The  tumor  cells  gradually 
disappear  by  a  process  which  appears  to  be  some  form  of  cyto- 
lysis,  which  is  then  followed  by  their  absorption. 

It  is  evident  that  we  have  to  do  here  with  an  agent  of  extra- 
ordinary character;  it  destroys  tumor  cells  which  have  power 
of  proliferating,  and  of  infiltrating  and  destroying  surrounding 


Fig.  93. — Section  from  a  nodule  of  carcinoma  of  the  skin.     Case  53. 


Fig.  94.— Section  from  the  horder  of  a  carcinoma  ulcer,  showing  changes  pro- 
duced by  ar-rays.     Case  53. 

267 


Fig.  95. — Same  as  Fig.  94,  under  higher  power. 


CHANGES   IN    CARCINOMATOUS   TISSUE    UNDER    X-RAYS.      271 

tissues,  almost  regardless  of  their  nature  and  structure.  It 
attacks  the  youngest  and  most  actively  proliferating  and  most 
destructive  cells,  while  its  effect  on  the  normal  tissue  is  of 
markedly  less  severity. 

The  final  stage  produced  in  the  successful  use  of  x-rays  in 
the  treatment  of  carcinoma  is  shown  in  microphotograph 
(Fig.  96).  This  section  is  taken  from  a  piece  of  tissue  excised 
from  a  healthy  scar  exactly  at  the  site  of  the  previous  car- 
cinoma (see  Case  46,  Figs.  115  to  117).  As  will  be  seen,  the 
carcinomatous  tissue  has  been  replaced  by  a  dense  layer  of 
healthy  connective  tissue,  whose  fibers  present  a  strikingly 
regular  appearance.  The  surface  is  covered  by  a  thick  layer 
of  healthy  epithelium.  There  are  no  papilla  remaining.  At  no 
place  is  there  the  slightest  suspicion  of  carcinomatous  infiltration. 

The  healed  edge  of  a  rodent  ulcer  examined  by  Sequeira  * 
showed  much  the  same  condition  that  was  found  in  my  sections 
of  scar  tissue.  He  reports  that  it  consisted  largely  of  connective 
tissue.  The  epithelial  cells  seemed  to  have  undergone  a  peculiar 
change,  the  nuclei  being  irregular  and  the  outline  of  the  cells 
ill  defined. f 

*Brit.  Med.  Jour.,  1901,  i,  p.  332. 

f  The  foregoing  are  the  facts  as  to  the  pathological  changes  caused  in  the 
tissues  by  a>rays.  There  has  been  a  good  deal  of  speculation  indulged  in  with- 
out the  foundation  of  histological  studies,  and  it  may  be  interesting  to  consider 
these  theories  for  a  moment. 

One  of  the  first  explanations  offered  was  that  of  Kaposi  (Wien.  med.  Presse, 
1899,  xl,  p.  1285),  which  has  been  widely  quoted  on  account  of  his  eminence. 
It  was  to  the  effect  that  "  in  diseased  areas  where  there  is  inflammatory  infiltra- 
tion or  formation  of  new  tissue,  the  cellular  elements  are  altered  in  their  molecu- 
lar structures,  and  are  thus  prepared  for  resorption."  Huntington  (Annals  of 
Surgery,  1901,  xxxiv,  p.  808)  suggested  that  the  x-ray  changes  in  tissues  are  de- 
pendent upon  irritation  of  the  peripheral  nerves,  with  secondary  paralysis  of 
the  vasomotor  system.  Hopkins  (Phila.  Med.  Jour.,  1900,  v,  p.  808)  suggested 
that  they  were  due  to  the  destruction  of  the  nerve-supply  of  the  exposed  tissues, 
and  offered  the  name  white  gangrene  for  the  condition  (though  why  white  gan- 
grene, rather  than  yellow,  or  green,  or  mauve,  is  not  apparent,  as  they  are  all 
equally  inaccurate  in  their  description  of  the  condition).  Blackmarr  (American 
Electro-Therapeutic  and  X-Ray  Era,  1901,  1,  No.  3,  p.  1)  suggested  that  ar-ray 
vibrations  caused  increased  vitality  in  the  leucocytes.  Sharpe  (Archives  of  the 
Kontgen  Ray,  1901,  v,  p.  85)  and  others  suggested  that  they  are  due  to  a 
primary  effect  upon  the  capillaries. 

The  accurate  studies  which  have  been  made  upon  the  subject  are  sufficient  to 
show  the  weak  points  in  these  various  suggestions.  These  studies  do  not  show 


272  HISTOLOGICAL    CHANGES    PRODUCED    BY    X-RAYS. 

The  findings  of  different  observers  thus  agree  very  closely. 
On  first  view  the  findings  of  Oudin,  Barthelemy,  and  Darier 
appear  to  be  at  variance  with  the  others,  in  that  they  report 
very  slight  changes  in  the  corium,  but  this  discrepancy  dis- 
appears when  we  remember  that  their  experiments  were  made 
upon  areas  of  alopecia  "unaccompanied  by  burns."  Practi- 
cally all  agree  in  describing  two  sorts  of  changes:  first,  evidences 
of  peculiar  structural  changes  in  the  cells  themselves;  second, 
certain  proliferative  changes  in  the  inner  coats  of  the  blood- 
vessels. These,  I  believe,  must  be  accepted  as  the  characteristic 
features  in  the  process.  It  is 'striking  evidence  of  the  uniformity 
of  these  changes,  and  of  the  thoroughness  with  which  the 
subject  has  been  studied,  that  so  many  independent  observers 
have  agreed  so  closely  in  emphasizing  in  their  descriptions 
the  same  facts.  The  process  is  one  primarily  affecting  the 
tissue  cells  themselves.  There  is  evidence  first  of  stimulation 
of  cellular  activity,  and  later,  if  the  effect  is  at  all  intense, 
there  follows  disorganization  of  the  affected  cells.  The  changes 
occur  first  and  most  markedly  in  the  epithelium,  and  next 
in  the  blood-vessels,  but  it  is  likely  that  they  develop  also, 
though  to  a  much  less  degree,  in  the  cells  of  all  the  tissues 
of  the  affected  area.  It  is  to  be  noted  that  the  changes  in 
the  blood-vessels  do  not  precede  the  changes  in  the  other 
tissues,  but  are  found  later  at  least  than  the  first  changes  in 
the  epithelium.  The  changes  in  the  cells,  therefore,  are  probably 
not  primarily  a  result  of  circulatory  disturbance,  for  they 

that  the  nerves  are  primarily  affected,  or  that  any  single  tissue  is  affected  pri- 
marily to  the  exclusion  of  any  other.  The  important  role  played  hy  the  capil- 
lary changes  has  already  been  called  attention  to.  Blackmarr's  suggestion  and 
Kaposi's  suggestion  are  in  line  with  the  effects  found,  but  are  hardly  definite 
enough  to  be  of  any  scientific  value.  The  most  far-fetched  suggestion  is  that  of 
Hopkins,  that  the  changes  are  due  to  electrical  discharges  through  the  tissues; 
that  for  this  discharge  the  nerves  form  the  chief  conductor;  and  that  they  are 
burned  out  by  an  overload  of  electricity  in  the  same  way  that  electrical  wires 
which  are  overloaded  are  burned  out.  Of  course,  this  suggestion  entirely  ig- 
nores the  facts.  There  is  no  reason  to  believe  that  any  induced  electricity  is 
discharged  through  the  tissues,  but  even  admitting  that  there  was  a  discharge  of 
electricity  through  the  tissues,  there  is  nothing  to  indicate  that  the  nerves 
would  be  any  better  conductors  of  this  than  the  other  tissues.  In  fact,  it  is 
known  that  they  are  not,  and  the  pathological  findings  have  shown  that  the 
changes  in  the  nerves  are  not  particularly  prominent. 


.;.,••-. 


Fig.  96. — Section  from  a  scar  following  the  treatment  by  x-rays  of 
cutaneous  carcinoma. 


18 


273 


CHANGES   IN    CARCINOMATOUS   TISSUE    UNDER   X-ftAYS.     275 

come  earlier  than,  or  at  least  at  the  same  time  as,  the  signs 
of  vascular  lesions.  Accordingly  the  changes  in  the  blood- 
vessels are  not  the  essential  cause  of  x-ray  injuries,  but  are 
probably  analogous  to  those  which  occur  in  the  other  tissues 
at  the  same  time.  It  is  doubtless  true  that  the  changes  in 
the  blood-vessels  are  factors  of  importance  in  the  later  changes 
that  occur  in  the  tissues,  but  it  is  not  to  be  lost  sight  of  that 
they  come  into  play  after  the  cellular  disturbances  are  already 
well  along  in  their  development. 

It  is  an  interesting  fact  that  attention  has  not  been  called 
especially  to  changes  in  the  nerves. 

The  changes  seen  in  pathological  tissues  under  x-ray  treat- 
ment present  the  same  characteristics  as  those  seen  in  healthy 
tissues  exposed  to  x-rays.  There  is  first  evidence  of  stimulation 
of  certain  intracellular  processes,  and  later  degeneration  and 
absorption  of  the  diseased  tissues,  the  whole  accompanied  by 
an  inflammatory  reaction,  which  first  aids  in  the  destruction 
of  the  degenerating  tissue  and  then  in  its  replacement  with 
healthy  connective  tissue.  Accompanying  the  whole  process 
are  the  characteristic  changes  in  the  blood-vessels.* 

The  especially  significant  feature  is  the  degeneration  and 
disappearance  of  pathological  tissues  under  x-ray  effects  which 
are  not  sufficiently  intense  to  destroy  the  healthy  stroma. 
This  is  evidently  the  key-note  to  the  use  of  x-rays  in  the  treat- 
ment of  certain  diseases,  the  morbid  products  of  which  must 
be  disposed  of  in  order  to  get  relief;  a  reaction  must  be 

*  Hektoen  has  suggested  in  a  personal  communication  to  me  that  the  changes 
iu  the  blood-vessels  may  be  at  times  partially  accounted  for  by  the  fact  that  as 
the  tissues  of  any  area  involved  shrink  iimler  the  effect  of  exposure  to  x-rays,  the 
extent  of  the  territory  supplied  by  the  corresponding  arteries  and  veins  is  di- 
minished. The  researches  of  Thoma  have  shown  that  under  such  conditions 
there  is  a  new  growth  of  connective  tissue  in  the  intima  of  the  blood-vessels,  re- 
sulting in  a  compensatory  narrowing  of  the  lumina,  which  thus  become  ad- 
justed in  size  to  the  needs  for  blood  in  the  parts  involved.  Perhaps  some  of  the 
endovascular  productive  changes  seen  in  tissues  exposed  to  x-rays  are  explain- 
able on  the  score  of  this  compensatory  proliferation  described  by  Thoma.  The 
difficulty,  however,  in  the  way  of  this  theory  is  that  these  changes  in  the  blood- 
vessels are  seen  before  there  is  any  shrinkage  of  the  tumor,  and  before  there  is 
any  diminution  in  the  vascular  needs  of  the  part.  Indeed  there  would  seem  to 
be  an  increased  demand  for  blood  in  the  affected  parts,  at  the  very  time  that 
these  changes  in  the  blood-vessels  occur 


276  HISTO LOGICAL    CHANGES    PRODUCED    BY    X-RAYS. 

produced  sufficient  to  cause  destruction  of  the  diseased  tissues 
which  constitute  the  pathological  process,  but  not  sufficient 
to  destroy  the  surrounding  healthy  tissue.  As  to  why  these 
changes  are  produced  in  tissues  by  x-rays,  the  explanation 
doubtless  lies  in  the  fact  that  tissue  cells  are  susceptible  to 
energy  in  the  form  of  x-rays,  and  the  result  of  the  absorption 
of  this  energy  by  the  cells  is  disarrangement  of  the  normal 
intracellular  structure.  If  the  intensity  of  the  x-ray  effect  is 
sufficient,  this  derangement  of  the  intracellular  structure  goes 
on  to  the  point  of  disorganization,  and  complete  disintegration 
of  the  cells.  If  this  view  is  correct, — and  in  my  opinion  there 
is  no  doubt  of  its  accuracy, — the  effect  of  x-rays  upon  cells 
is  entirely  analogous  to  the  effect  of  x-rays  or  light  upon  sus- 
ceptible salts  like  silver  salts,  in  which  the  absorption  of  the 
x-rays  causes  a  complete  rearrangement  of  the  molecular 
structure.  This  susceptibility  to  x-ray  energy  is  certainly  most 
marked  in  the  epithelial  cells.  Xow,  the  epithelium  is  the 
tissue  of  the  skin  which  has  particularly  to  do  with  protecting 
the  subcutaneous  tissues  against  the  effects  of  sunlight,  and 
is  accordingly  most  affected  by  light  rays.  It  is,  therefore, 
not  to  be  wondered  at  that  epithelium  should  show  a  greater 
susceptibility  than  other  tissues  of  the  skin  to  the  effect  of 
an  agent  so  closely  analogous  to  light  rays  as  are  x-rays. 

This  effect  of  x-rays  on  tissues  is  shown  under  suitable  con- 
ditions in  normal  tissues,  but  it  occurs  most  readily  in  the 
tissues  of  diseased  conditions  such  as  carcinoma,  sarcoma,  and 
tuberculosis.  As  to  why  certain  diseased  tissues,  like  those  of 
tuberculosis,  sarcoma,  and  carcinoma,  show  a  greater  suscepti- 
bility to  the  influence  of  x-rays  than  normal  tissues,  the  expla- 
nation, I  believe,  is  not  far  to  seek.  The  pathological  tissues 
are  made  up  of  relatively  unstable  cells  which  readily  degen- 
erate and  are  relatively  easily  destroyed  by  any  disturbance 
of  nutrition.  It  is  likely,  therefore,  that  such  cells  would  prove 
more  susceptible  than  normal  tissues  to  an  agent  like  x-rays, 
whose  effect  so  distinctly  interferes  with  the  normal  pro- 
cesses in  the  cells. 

Whether  the  above  explanations  are  correct  or  not  makes 
very  little  practical  difference.  The  important  fact,  of  which 


CHANGES   IN   CARCINOMATOUS   TISSUE   UNDER   X-RAYS.     277 

abundant  evidence  is  given  in  the  microscopic  studies  that 
have  been  made,  is  that  there  is  a  derangement  of  the  structures 
of  the  cells  brought  under  the  influence  of  x-rays,  and  that 
this  derangement  occurs  more  readily  in  certain  diseased 
tissues  than  in  normal  tissues,  so  that  to  a  certain  extent  the 
x-rays  may  be  said  to  have  a  selective  effect  upon  such  diseased 
tissues.  These  diseased  tissues  accordingly  may  under  suitable 
conditions  be  made  to  undergo  degeneration  and  absorption 
and  replacement  by  healthy  connective  tissue  without  the 
destruction  of  the  healthy  elements.  This  from  a  therapeutic 
standpoint  is  the  important  fact  that  is  gained  from  a  study 
of  tissues  affected  by  x-rays;  and  it  is  a  fact  pregnant  with 
possibilities. 


CHAPTER  III. 
THE  EFFECT  OF  X-RAYS  ON  BACTERIA. 

The  Effect  of  X-rays  on  Bacteria  in  Cultures. — There  is  some 
conflict  of  statement  in  the  literature  concerning  the  effect 
of  x-rays  upon  bacteria.  A  number  of  writers,  largely  on 
the  basis  of  clinical  experience  with  x-rays  in  bacterial  diseases 
and  without  having  experimental  data  for  their  assumption, 
have  assumed  that  x-rays  have  decided  germicidal  properties. 
And  a  few  observers  have  reported  experiments  upon  bacteria 
in  cultures,  tending  to  show  the  existence  of  positive  germicidal 
properties  in  x-rays  themselves.  The  report  upon  this  subject 
which  has  received  most  consideration  is  that  made  by  Riecler.* 
Rieder  exposed  fresh  plate  cultures  of  the  cholera  vibrio, 
Bacillus  coli  communis,  Bacillus  typhosus,  the  bacillus  of  diph- 
theria, and  others,  to  the  effect  of  x-rays  for  periods  varying 
from  forty  minutes  to  an  hour.  As  a  control  experiment, 
part  of  each  of  these  cultures  was  protected  from  the  effect 
of  x-rays  by  a  cover  of  sheet-lead.  He  reports  that  in  all  cases 
colonies  developed  in  those  portions  covered  by  the  lead, 
while  the  parts  of  the  cultures  exposed  to  the  rays  did  not 
grow.  The  same  effect,  however,  was  not  produced  upon 
developed  colonies  of  bacteria.  These  old  colonies  were  not 
destroyed  by  the  exposures,  but  there  was  no  further  develop- 
ment. The  growth  of  tubercle  bacilli  was  not  prevented,  but 
was  distinctly  inhibited.  He  excludes  the  influence  of  chemical 
changes  in  the  culture-media  in  preventing  the  growth  of 
the  cultures,  because  later  he  was  able  to  obtain  good  growth 
of  bacteria  in  the  areas  that  had  been  sterilized  by  x-rays, 
and  by  other  checks  he  excluded  the  influence  of  heat  and 
electrical  effects.  Rieder  f  has  recently  reported  a  practical 
repetition  of  his  experiments,  and  has  reaffirmed  his  findings. 

*Miinch.  med.  Wochenschr.,  1898.  xlv.  p.  773. 
f  Munch,  med.  "Wochenschr. ,  1902,  xlix,  p.  402. 

278 


THE    EFFECT   OF   X-RAYS    ON    BACTERIA    IN    CULTURES.       279 

Rudis-Jicinsky  *  has  also  presented  a  series  of  experiments 
tending  to  show  positive  bactericidal  properties  in  x-rays. 
His  results  are  expressed  in  the  following  table: 

UNDER  X-RAY  IRRADIATION.  MEDIA. 

Acid.  Alkaline. 

Bacillus  anthracis Negative.  Negative. 

Bacillus  tuberculosis,  in  sputum,  destroyed  in  48  min.  Negative. 

Bacillus  tuberculosis,  in  flask,  destroyed  in  .    .  50  min.  Growth  accentuated. 

Spirillum  choleras,  in  flask,  destroyed  in  .    .    .51  min.  55  min. 

Bacillus  diphtherias,  in  flask,  destroyed  in    .    .  46  min.  48  min. 

Bacillus  typhi  abdominalis,  in 45  min.  49  min. 

Streptococcus Negative.  Negative. 

Staphylococcus Negative.  Negative. 

Micrococcus  pyogenes  albus Negative.  40  min. 

Micrococcus  gonorrheas,  destroyed  in 35  min.  40  min. 

Thus  it  will  be  seen  that  his  results  varied  from  accentuation 
of  growth  of  Bacillus  tuberculosis  in  alkaline  medium  to  the 
destruction  of  the  gonococcus  in  an  acid  medium  in  thirty- 
five  minutes. 

The  above  findings  of  Rieder  and  Rudis-Jicinsky  are  not 
in  accord  with  the  preponderance  of  evidence  upon  this  subject. 
Many  experimenters  have  worked  in  this  field,  and  on  the  whole 
the  evidence  is  overwhelming  that  x-rays  in  themselves  possess 
no  marked  bactericidal  properties. 

Berton  f  found  that  the  diphtheria  bacillus  in  bouillon 
cultures  was  not  influenced,  either  in  growth  or  virulence, 
by  exposures  of  sixteen,  thirty-two,  and  sixty-four  hours. 

Minck  J  found  that  fresh  cultures  of  typhoid  bacillus  on  agar 
plate,  after  an  exposure  of  three  hours,  at  a  distance  of  10  cm. 
from  the  tube,  showed  when  incubated  no  difference  in  growth 
from  an  unexposed  control  plate. 

Wittlin  §  repeated  Minck 's  experiments  with  Bacillus  typho- 
sus,  Bacillus  diphtheria?,  Staphylococcus  aureus,  and  Vibrio 
choleras,  and  concludes  that  Rontgen  rays  have  no  influence  on 
the  growth  or  life  of  bacteria. 

*N.  Y.  Med.  Jour.,  1901,  Ixxiii,  p.  364. 

f  La  Semaine  Mcdicale,  1896,  xvi,  p.  283. 

j  Munch,  med.  Wochenschr.,  1896,  xliii,  pp.  101,  202. 

gCentralbl.  f.  Bakt.,  2.  Abth.,  Bd.  ii,  p.  676. 


280  THE    EFFECT    OF    X-RAYS    OX    BACTERIA. 

Blaize  and  Sambuc  *  found  that  three  hours '  exposure  had 
no  effect  on  Bacillus  anthracis. 

Bergonie  and  Mongour  t  found  that  they  were  unable  to 
reduce  the  virulence  of  tubercle  bacilli  by  exposing  sputum 
to  x-rays. 

Wolfenden  and  Forbes-Ross  J  report  that  as  a  result  of 
two  years'  study  of  this  subject  they  find  it  impossible  by 
any  ordinary  long  exposure  to  high  vacuum  tubes  to  kill  growths 
of  bacilli  or  cocci  by  x-rays. 

Basset-Smith  §  found  that  broth  cultures  of  Bacillus  typhosus, 
Bacillus  coli  communis,  and  cholera  vibrio  were  uninfluenced 
by  exposures  for  fifteen  minutes  on  three  successive  days  with 
the  tube  at  a  distance  of  six  inches.  Bacillus  pestis  was 
perhaps  slightly  inhibited  in  growth. 

Lyon,  ||  Delepine,**  and  Sabrazes  and  Riviere, ft  as  a  result 
of  their  experiments,  have  come  to  similar  conclusions. 

This  subject  has  been  gone  over  recently  in  a  very  careful 
series  of  experiments  by  Prof.  F.  Robert  Zeit,|J  of  the  North- 
western University.  His  experiments  were  as  follows: 

"Experiments. — («)  Bouillon  and  hydrocele-fluid  cultures,  in 
test-tubes,  of  Bacillus  pyocyaneus,  prodigiosus,  typhosus,  an- 
thracis, and  diphtheria?  were  exposed  to  Rcntgen  rays,  at  a 
distance  of  2  centimeters  from  the  tube,  for  two,  five,  ten, 
twenty,  and  forty-eight  hours,  without  any  effect  whatever 
upon  pigment  production,  growth,  motility,  or  virulence. 

"A  repetition  of  Rieder's  experiments  proved  negative. 

"  (6)  Suspensions  of  the  same  bacteria  in  agar  were  plated 
out.  For  the  glass  cover  of  the  plate  I  substituted  a  lead 
plate  5  mm.  thick,  which  had  an  oval  window  cut  out  in  the 
center.  The  plate  was  then  exposed  to  the  rays  with  its  agar 
film  toward  the  tube,  at  a  distance  of  20  mm.,  for  one-half, 
one,  two,  and  four  hours.  When  incubated,  the  exposed 

*Compt.  rend.  Soc.  Biol.,  1897,  Serie  10,  vol.  iv,  p.  689. 

t  Bull.  Acad.  Med.,  1897,  Serie  3.  vol.  xxxviii,  p.  66. 

%  Archives  of  the  Rontgen  Ray,  1900,  v,  p.  3. 

\  Archives  of  the  Rontgen  Ray,  1901,  v,  p.  47. 

||  Lancet,  1896,  i.  p.  513.  **  Brit.  Med.  Jonr.,  1896,  i,  p.  f>59. 

ttCompt.  Rend.  Acad..  Serie  c.  1897.  cxxiv,  p.  979. 

JJ  Jour.  Am.  Med.  Assoc.,  1901,  xxxvii,  p.  1432. 


THE   EFFECT   OF  X-RAYS   ON   BACTERIA   IN   CULTURES.      281 

portion  of  the  agar  showed  just  as  many  colonies  as  the 
non-exposed  portions. 

"  (c)  A  serum  plate  was  smeared  thickly  with  sputum  con- 
taining from  50  to  100  tubercular  bacilli  to  the  field.  The 
plate  was  exposed  without  cover  for  six  hours  to  the  rays, 
at  a  distance  of  20  mm.  from  the  tube.  Three  guinea-pigs 
were  inoculated,  of  which  one  died  in  five  weeks  and  one  in 
seven  weeks  of  acute  miliary  tuberculosis.  One  is  alive  yet, 
but  is  tubercular.  It  has  enlarged  inguinal  glands,  constantly 
elevated  temperature,  and  has  continually  lost  in  weight." 

His  conclusions  are  as  follows: 

"Bouillon  and  hydrocele-fluid  cultures  in  test-tubes,  of  non- 
resistant  forms  of  bacteria,  could  not  be  killed  by  Rontgen 
rays  after  forty-eight  hours'  exposure  at  a  distance  of  20  mm. 
from  the  tube. 

"Suspensions  of  bacteria  in  agar  plates  exposed  for  four 
hours  to  the  rays,  according  to  Rieder's  plan,  were  not  killed. 

"Tubercular  sputum  exposed  to  the  Rontgen  rays  for  six 
hours  at  a  distance  of  20  mm.  from  the  tube  caused  acute 
miliary  tuberculosis  of  all  the  guinea-pigs  inoculated  with  it. 

"Rontgen  rays  have  no  direct  bactericidal  properties."* 

*  Zeit  has  also  experimented  upon  the  effect  of  direct,  alternating,  and  Tesla 
or  high  frequency  and  high  potential  currents  upon  bacteria,  and  on  the  effect  of 
a  magnetic  field  upon  bacteria.  These  experiments  are  not  quite  pertinent  to 
the  question  that  we  have  under  discussion,  but  the  effects  of  electricity  are  so 
confused  with  those  of  x-rays  in  many  minds  that  I  venture  to  quote  here  his 
conclusions  from  these  experiments. 

"1.  A  continuous  current  of  260  to  320  milliamperes,  passed  through  bouillon 
cultures,  kills  bacteria  of  low  thermal  death-points,  in  ten  minutes,  by  the  pro- 
duction of  heat — 98.5°  C.  The  antiseptics  produced  by  electrolysis  during  this 
time  are  not  sufficient  to  prevent  growth  of  even  non-spore-bearing  bacteria. 
The  effect  is  a  piirely  physical  one. 

"2.  A  continuous  current  of  48  milliamperes  passed  through  bouillon  cul- 
tures for  from  two  to  three  hours  does  not  kill  even  non-resistant  forms  of  bac- 
teria. The  temperature  produced  by  such  a  current  does  not  rise  above  37°  C., 
and  the  electrolytic  products  are  antiseptic  but  not  germicidal. 

"3.  A  continuous  current  of  100  milliamperes  passed  through  bouillon  cul- 
tures for  seventy-five  minutes  kills  all  non-resistant  forms  of  bacteria,  even  if 
the  temperature  is  artificially  kept  below  37°  C.  The  effect  is  due  to  the  forma- 
tion of  germicidal  electrolytic  products  in  the  culture.  Anthrax  spores  are 


282  THE    EFFECT    OF   X-RAYS    OX    BACTERIA. 

In  the  light  of  these  findings  from  so  many  observers  working 
independently,  the  conviction  cannot  be  escaped  that  the 
influence  of  x-rays  per  se  upon  bacteria  is  practically  nil.  It 
may  be  true  that  very  long  exposures,  with  great  quantities 
of  light,  produce  an  appreciable  influence  upon  bacteria,  but 
this  destructive  effect  upon  bacteria  is  so  infinitesimal  compared 
with  the  effect  upon  highly  organized  animal  tissues  that  it 
may  be  regarded  as  nil,  and  for  all  practical  purposes  might 
as  well  not  exist.  This  fact  is  not  difficult  to  reconcile  with 
the  striking  effect  of  x-rays  upon  highly  organized  animal 
tissues.  In  bacteria  we  have  vegetable  organisms  of  the 
highest  power  of  resistance,  and  when  we  remember  how  much 
greater  relatively  is  their  power  of  resistance  to  heat  and  cold 
and  other  destructive  agents  than  that  which  is  possessed 
by  animal  tissues,  it  is  not  surprising  that  they  show  so  strong 
a  power  of  resistance  to  the  influence  of  x-rays.  To  express 

killed  in  two  hours.  Subtilis  spores  were  still  alive  after  the  current  was 
passed  for  three  hours. 

"4.  A  continuous  current  passed  through  bouillon  cultures  of  bacteria  pro- 
duces a  strongly  acid  reaction  at  the  positive  pole,  due  to  the  liberation  of  chlo- 
rine, which  combines  with  oxygen  to  form  HC1.  The  strongly  alkaline  reaction 
of  the  bouillon  culture  at  the  negative  pole  is  due  to  the  formation  of  sodium 
hydroxide  and  the  liberation  of  hydrogen  in  gas  bubbles.  With  a  current  of 
100  milliamperes  for  two  hours,  it  required  8.82  milligrams  of  H.,SO4  to  neu- 
tralize 1  cc.  of  the  culture  fluid  at  the  negative  pole,  and  all  the  most  resistant 
forms  of  bacteria  were  destroyed  at  the  positive  pole,  including  anthrax  and 
subtilis  spores.  At  the  negative  pole  anthrax  spores  were  killed  also,  but  subtilis 
spores  remained  alive  for  four  hours. 

"5.  The  continuous  current  alone,  by  means  of  du  Bois  Reymond's  method 
of  non-polarizing  electrodes,  and  exclusion  of  chemical  effects  by  ions  in  Kru- 
ger's  sense,  is  neither  bactericidal  nor  antiseptic.  The  apparent  antiseptic  effect 
on  suspensions  of  bacteria  is  due  to  electric  osmose.  The  continuous  electric 
current  has  no  bactericidal  nor  antiseptic  properties,  but  can  destroy  bacteria 
only  by  its  physical  effects  (heat)  or  chemical  effects  (the  production  of  bacteri- 
cidal substances  by  electrolysis). 

"  6.  A  magnetic  field,  either  within  a  helix  of  wire  or  between  the  poles  of  a 
powerful  electro-magnet,  has  no  antiseptic  or  bactericidal  effects  whatever. 

"  7.  Alternating  currents  of  a  3-inch  Ruhmkorrf  coil,  passed  through  bouillon 
cultures  for  ten  hours,  favor  growth  and  pigment  production. 

"8.  High  frequency,  high  potential  currents — Tesla  currents — have  neither 
antiseptic  nor  bactericidal  properties  when  passed  around  a  bacterial  suspension 
within  a  solenoid.  When  exposed  to  the  brush  discharges,  ozone  is  produced 
and  kills  the  bacteria." 


EFFECT   OF   X-RAYS    ON    BACTERIA    IN    LIVING    TISSUES.      283 

it  in  another  form,  there  is  nothing  inconsistent  between  the 
pronounced  effect  of  x-rays  upon  susceptible  animal  tissues, 
and  the  practical  absence  of  effect  of  x-rays  upon  resistant 
vegetable  organisms  of  the  lowest  forms. 

As  has  been  suggested  by  Freund,*  the  destruction  of  bacteria 
in  cultures  by  exposures  to  x-rays  may  be  due  to  the  electrical 
discharges,  and  in  the  light  of  other  experiments  it  is  probable 
that  such  an  explanation  must  be  sought  to  account  for  the 
results  of  Rieder's  and  Rudis-Jicinsky's  experiments. 

Effect  of  X-rays  on  Bacteria  in  Living  Tissues. — The  behavior 
of  bacteria  in  living  tissues  under  the  influence  of  x-rays  is 
quite  different  from  that  when  they  are  growing  in  inert  media. 
When  a  suppurating  ulcer  is  exposed  to  a  sufficient  extent 
to  x-ray  influence,  unmistakable  evidence  of  interference  with 
the  growth  of  the  pus  organisms  is  shown.  The  discharge 
changes  from  pus  to  a  sero-purulent  and  then  to  a  sero-fibrinous 
fluid,  and  soon  the  ulcer  becomes  clean  and  free  from  evidence 
of  contamination  with  pus  organisms.  This  drying-up  and 
cleaning  of  infected  ulcers  has  been  noted  by  numerous  ob- 
servers. Attention  has  been  called  to  it  by  Startin  f  in  lupus, 
Greenleaf  J  in  lupus,  Sequeira  §  in  rodent  ulcer,  Eijkman  || 
in  carcinoma,  and  many  others.  It  occurs  regardless  of  the 
character  of  the  ulcer.  I  have  repeatedly  seen  dirty,  septic 
ulcers  of  carcinoma,  syphilis,  and  lupus  become  clean  and 
sterile  under  the  influence  of  x-rays  alone  without  the  use 
of  antiseptics;  at  times,  indeed,  under  conditions  most  un- 
favorable for  the  maintenance  of  cleanliness.  This  inhibition 
of  the  formation  of  pus  and  checking  of  septic  processes  under 
the  influence  of  x-rays  is  shown  best  in  diseases  of  the  skin 
which  are  essentially  due  to  infection  with  the  ordinary  pyogenic 
organisms.  Case  15,  page  351,  of  sycosis,  illustrates  well  this 
property  of  x-rays.  .  This  was  a  case  of  sycosis  due  to  simple 
pus  infection  without  contamination  by  the  ringworm  fungus, 

*  Sitzungsberichten  kaiserl.  Akad.  der  Wissqiichaften  in  "Wien.  Math.-natur- 
wissens.  Classe,  Bd.  cix,  Abth.  ii,  Oct.,  1900. 
t Lancet,  London,  1901,  ii,  p.  144. 
J  Buffalo  Med.  Jour.,  1901,  xli,  p.  189. 
3  Brit.  Med.  Jour.,  1901,  ii,  p.  851. 
||  Krebs  und  Rontgenstrahlen,  1902,  Haarlem. 


284  THE    EFFECT    OF   X-RAYS    OX    BACTERIA. 

and  it  had  resisted  irritating  antiseptic  treatment  for  several 
months.  At  the  time  that  the  x-ray  exposures  were  begun 
the  hair  follicles  were  freely  discharging  pus,  which  was  full 
of  common  pyogenic  organisms.  Under  x-ray  exposures  alone 
the  condition  entirely  cleared  up;  the  septic  process  was  stopped 
and  the  bacteria  in  the  tissue  entirely  disappeared.  The 
literature  is  full  of  similar  cases.  The  inference  is  positive, 
from  the  clinical  behavior  of  such  septic  processes,  that  the 
ordinary  pyogenic  organisms,  when  situated  in  superficial 
tissues,  are  destroyed  under  the  influence  of  x-rays. 

Similar  germicidal  effect  of  x-rays  upon  mycelial  fungi  is 
shown  in  the  results  in  the  treatment  of  tine'a  barbse,  tinea 
tonsurans,  and  favus,  which  have  been  reported  by  several 
observers.  The  cure  of  lupus  under  x-rays  also,  and  the  result 
in  several  other  bacterial  diseases,  indicate  the  effect  of  x-rays 
upon  a  number  of  other  pathogenic  organisms.  As  showing 
the  effect  of  x-rays  on  tubercle  bacilli,  the  experiments  of 
Lortet  and  Genoud  *  are  of  interest.  They  inoculated  in  the 
inguinal  region  eight  guinea-pigs  of  the  same  size  and  weight 
with  material  from  the  spleen  of  a  tuberculous  guinea-pig. 
Of  these  eight,  three  were  chosen  at  random  and  given  exposures 
daily  over  the  inguinal  regions.  The  three  remained  well, 
showing  only  small  nodules  at  the  points  of  injection,  which 
gradually  disappeared,  while  in  the  five  unexposed  pigs  tuber- 
culous ulcers  resulted  at  the  points  of  inoculation  and  the  pigs 
became  thin. 

The  fact  that  organisms  in  living  tissues  can  be  destroyed 
by  exposure  to  x-rays,  while  the  same  organisms  in  inert  cul- 
tures are  uninfluenced  by  x-ray  exposures,  proves  positively 
that  it  is  not  the  influence  of  x-rays  per  se  that  causes  the 
destruction,  but  that  the  tissues  themselves,  doubtless  under 
conditions  of  activity  excited  by  the  x-rays,  play  the  important 
role  in  the  germicidal  process.  It  may  well  be  imagined  that 
this  process  is  in  the  nature  of  stimulation  of  the  cells,  which 
are  rendered  thereby  better  able  to  take  care  of  the  invasion 
of  the  organisms.  That  the  effect  on  bacteria  is  caused  by 
increased  phagocytosis  has  been  suggested  by  Blaise  and 

*  Semaine  Medicale,  1896,  xvi,  p.  266. 


EFFECT    OF   X-RAYS    ON    BACTERIA    IN    LIVING    TISSUES.      285 

Sambuc,*   Bergonie   and   Mongour,f  Basset-Smith,  J  Ullman,§ 
and  various  other  writers. 

Whether  these  destructive  effects  upon  micro-organisms  may 
be  produced  deep  in  the  tissues  or  not,  is  as  yet  uncertain. 
It  is  the  same  question  in  another  form  as  the  effect  of  x-rays 
upon  deep-seated  tissues.  If  sufficient  reaction  upon  the 
deeper  tissues  can  be  produced,  it  is  certainly  true  that  the 
same  effect  upon  bacteria  will  occur  that  is  seen  in  bacteria 
nearer  the  surface.  The  evidence  now  at  hand  points  rather 
against  very  marked  effect  upon  bacteria  deeply  situated 
in  the  tissues.  Inoculation  experiments  by  Scholtz||  and 
Miihsam  **  are  of  some  value  in  this  connection.  From  his 
experiments  Scholtz  concluded  that  x-rays  have  no  effect  in 
preventing  inoculation  tuberculosis  in  guinea-pigs.  Miihsam 
concluded  from  his  experiments  on  guinea-pigs  that  x-rays 
exercise  no  influence  on  general  tuberculosis,  but  that  they 
restrain  local  tuberculosis  to  a  point  where  its  action  is  very 
slight.  On  the  other  hand,  Ausset  and  Bedart  ft  naye  re- 
ported tubercular  peritonitis  cured  under  x-ray  exposures. 

*Compt.  rend.  Soc.  Biol.,  10  Serie,  vol.  iv,  1897,  p.  689. 

t  Bull.  Acad.  Med.,  1897,  3  Serie,  vol.  xxxviii,  p.  66. 

f  Archives  of  the  Rontgen  Ray,  1901,  v,  p.  47. 

\  Wien.  med.  Presse,  1900,  xli,  p.  954. 

||  Arch.  f.  Derm.  u.  Syph.,  1902,  lix,  p.  78. 
**Deutsch.  med.  Wochenschr.,  1898,  xxiv,  p.  715. 
tt  Echo  Medicale  du  Nord,  1899,  iii,  p.  604. 


CHAPTER  IV. 

THE  CAUSES  OF  THE   PHENOMENA   OBSERVED  IN 
TISSUES  AFTER  EXPOSURE  TO  X-RAYS. 

What  is  the  Active  Agent  in  the  Production  of  the  Tissue 
Changes  following  X-ray  Exposures? — Since  the  occurrence  of 
the  first  x-ray  burns  this  has  been  a  question  that  has  given 
rise  to  much  speculation.  In  the  early  days  of  x-rays  there 
was  a  tendency  to  attribute  x-ray  burns  not  to  x-ra}"S  them- 
selves, but  to  some  accompanying  factor  the  exclusion  of 
which  would  prevent  the  occurrence  of  x-ray  burns.  It  was 
suggested  that  they  might  be  due  to  particles  of  matter  from 
the  cathode  or  anticathode  driven  into  the  tissues ;  again,  that 
heat  was  a  factor  in  their  production;  again,  that  they  were 
due  to  chemical  compounds  formed  around  the  tube;  again, 
that  they  were  due  to  bacteria  driven  into  the  tissues;  again, 
that  they  were  due  to  ultra-violet  rays ;  and,  finally,  the  theory 
was  suggested,  and  has  been  very  tenaciously  held,  that  the 
effects  on  the  tissues  were  electrical  and  not  due  to  x-rays. 
Tesla  *  suggested  as  an  explanation  of  x-ray  injuries,  the 
possibility  of  cathodic  matter  at  a  high  temperature  being 
driven  into  the  tissues  by  x-rays  and  also  the  possibility  of  their 
being  due  to  ozone  generated  around  the  tube,  or  other  chemical 
compounds.  That  the  injuries  were  due  to  bacteria  driven 
into  the  tissues  has  been  suggested  by  several  writers.  That 
these  changes  are  of  electrical  origin  has  been  suggested  by 
Leonard,  t  Schiff,J  and  Freund.§  That  the  phenomena  are  due 
to  x-rays  themselves  has  been  urged  very  strongly  from  the 
beginning  by  various  observers :  Elihu  Thomson,  ||  Jones,** 

*  Electrical  Review,  1897,  xxx,  p.  207. 
t  American  X-ray  Journal,  1898,  iii.  p.  453. 
i  Wien.  med.  Presse,  1902,  xliii,  p.  10-2.5. 
£  Klin,  therap.  Wochenschr.,  1901,  No.  1.  2. 

i|  Boston  Med.  and  Surg.  Jour.,  1896,  cxxxv,  p.  610.     American  X-ray  Jour- 
nal, 1898,  iii,  p.  451,  and  1899,  iv,  p.  494. 
**  Phila.  Med.  Jour.  1900,  v,  p.  63. 

286 


FACTORS    IX    PRODUCTION  OF  CHANGES   UNDER   X-RAYS.    287 

Scholtz,*  Kierib6ck,f  and  many  others.  Many  of  these  sug- 
gestions have  been  simply  speculation  without  the  support  of 
experimental  or  other  conclusive  data. 

The  experiments  of  Elihu  Thomson,  to  be  referred  to  later 
in  this  connection,  conclusively  establish,  I  believe,  the  fact 
that  none  of  these  factors  plays  an  important  role  except  the 
x-rays  themselves.  Before  taking  up  Thomson's  experiments, 
it  may  be  worth  while  briefly  to  consider  other  facts  bearing 
upon  this  question. 

In  the  first  place,  the  histological  findings  offer  strong  cor- 
roborative evidence  in  favor  of  the  theory  that  the  changes 
in  the  tissues  are  due  to  a  form  of  energy  of  high  actinic  power 
to  which  the  tissue  cells  are  susceptible.  The  histological 
changes  are  not  those  of  a  simple  destructive  process  or  an 
ordinary  inflammation,  such  as  would  be  due  to  heat  or  to 
the  presence  of  foreign  bodies  in  the  tissues  or  chemical  caustics 
or  ordinary  infection.  Great  primary  increase  in  the  pigment 
in  the  skin  and  thickening  of  the  layers  of  the  epidermis,  primary 
atrophy  of  the  gland  structures,  numerous  karyokinetic  figures, 
the  breaking  up  of  cell  nuclei  before  the  breaking  up  of  the 
cells  themselves,  peculiar  degeneration  in  the  embryonic  epithe- 
lium of  malignant  growths — these  are  not  the  changes  that 
one  sees  in  an  ordinary  inflammatory  process. 

As  to  the  possibility  of  x-ray  injuries  being  due  to  ozone 
or  other  chemical  compounds  formed  around  the  tube,  their 
presence  in  sufficient  quantity  to  account  for  the  changes 
does  not  occur.  In  favor  of  the  ozone  theory  Lilienthal  J 
called  attention  to  the  blanching  of  the  hairs,  suggestive  of 
ozone,  but  the  hairs  under  the  effects  of  x-rays  become  white, 
and  they  never  resemble  the  yellow  bleaching  of  the  hairs 
produced  by  ozone. 

To  determine  the  question  of  the  presence  of  particles  of 
platinum  driven  off  from  the  anticathode,  Gilchrist  §  submitted 
a  piece  of  tissue  from  an  x-ray  burn  to  Professor  Abel,  of  Johns 

*Arch.  f.  Derm.  u.  Syph.,  1902,  lix,  p.  87. 

fWien.  klin.  Wochenschr.,  1900,  xiii,  p.  1153.  Interstate  Medical  Journal 
1002,  ix,  pp.  1,  60. 

I  Medical  Record,  1897,  li,  p.  287. 

\  Johns  Hopkins  Hosp.  Bull.,  1897,  viii,  p.  17. 


288      CAUSE  OF  TISSUE-CHANGES   AFTER  X-RAY   EXPOSURES. 

Hopkins  University,  and  on  minute  chemical  examination  he 
discovered  no  platinum. 

As  to  the  theory  that  these  burns  are  due  to  the  driving 
in  of  bacteria,  no  facts  have  ever  been  brought  to  its  support, 
except  the  statement  that  x-ray  burns  occur  more  readily 
upon  surfaces  that  are  dirty.  I  have  already  called  attention 
to  the  fact  that  in  my  experience  this  is  not  the  case.  I  have 
made  careful  observations  upon  this  point,  and  in  long  expe- 
rience I  have  not  found  that  cleanliness  or  lack  of  cleanliness 
of  the  surface  exposed  to  x-rays  is  a  factor  of  any  importance 
in  the  production  of  x-ray  burns.  To  overcome  this  supposed 
factor  of  bacteria  in  producing  x-ray  burns,  it  was  suggested 
that  the  surface  to  be  exposed  be  covered  with  vaselin,  so  that 
the  entrance  of  the  bacteria,  and  the  resultant  injury,  should 
be  prevented.  Later,  paraffin  has  been  suggested.  Very  many 
observations  upon  surfaces  protected  by  vaselin  have  shown 
in  my  experience  that  vaselin  furnishes  no  protection  what- 
ever. I  have  similarly  protected  a  surface  in  one  case  very 
carefully  by  a  layer  of  paraffin  ^  of  an  inch  thick.  This  sur- 
face was  in  addition  kept  scrupulously  clean;  nevertheless  x-ray 
dermatitis  developed  as  promptly  as  under  other  circumstances. 
The  interposition,  also,  of  a  layer  of  aluminum  has  not 
interfered  with  the  production  of  x-ray  burns.  Indeed,  I 
am  willing  to  state  dogmatically  that  the  interposition  of  no 
substance  through  which  x-rays  can  penetrate  in  sufficient 
quantities  to  produce  a  photograph  will  prevent  the  pro- 
duction of  x-ray  dermatitis.  In  other  words,  nothing  that 
does  not  prevent  the  passage  of  x-rays  themselves  will  prevent 
x-ray  dermatitis. 

The  experiments  of  Prof.  Elihu  Thomson  *  upon  this  point 
are  worthy  of  detailed  account.  His  first  experiment  was 
upon  the  little  finger  of  his  left  hand,  which  he  exposed  to 
x-rays  from  a  tube  of  peculiar  construction,  at  a  distance  of 
about  1^  inches  from  the  target  for  one-half  hour.  This  was 
followed  by  a  severe  x-ray  burn,  which  first  began  to  develop 
nine  days  after  exposure.  He  makes  the  following  comments 
upon  the  experiment:  "I  am  willing  to  admit  that  ultra-violet 

*  Boston  Med.  and  Surg.  Jour.,  1896,  cxxxv.  p.  610. 


THOMSON'S  EXPERIMENTS.  289 

rays  might  possibly,  if  they  existed  in  large  quantities,  produce 
some  such  effect,  but  I  am  not  willing  to  admit  that  brush 
discharges  had  anything  to  do  with  it,  for  the  simple  reason 
that  the  potential  used  was  too  low,  being  produced  from  a 
small  24-plate  static  machine,  and  there  were  no  perceptible 
sparks  from  the  tube  to  the  finger.  I  am  strongly  of  the  opinion 
that  it  is  really  an  x-ray  effect,  and  that  neither  ultra-violet 
rays  nor  brush  discharges  have  anything  to  do  with  it.  I 
have  worked  with  the  brush  discharges  around  electrical  appa- 
ratus when  I  know  the  sum  total  of  effect  must  have  been 
many  times  what  could  possibly  have  been  obtained  in  this 
case,  assuming  that  they  existed  here  imperceptibly.  I  worked 
in  the  dark  and  saw  and  felt  none.  As  to  the  ultra-violet 
rays,  I  am  convinced  that  they  are  not  responsible  for  the 
results,  chiefly  because  of  the  effect  being  continued  laterally, 
on  each  side  of  the  finger,  a  portion  not  exposed  to  ultra-violet 
rays  under  the  conditions  unless  they  traversed  a  considerable 
thickness  of  the  dermal  layer,  filled  with  blood-vessels  which 
would  absorb  the  rays.  The  rays,  whatever  they  were,  came 
from  the  bombarded  spot,  and  were  limited  to  the  area  which 
Rontgen  rays  could  reach.  The  tube  was  a  blue  glass  tube 
with  a  clear  German  glass  window  of  about  1£  to  If  inches 
in  diameter  beside  the  bombarded  spot.  The  fingers  opposite 
the  blue  glass  were  not  affected,  as  this  is  so  dense  as  to  absorb 
the  Rontgen  rays.  Only  where  the  little  finger  was  opposite 
the  clear  glass  was  it  affected,  and  there  is  a  sharp  line  of  de- 
marcation between  that  portion  of  the  finger  and  the  portion 
back  of  the  blue  glass.  I  think  the  blue  or  purplish  glass 
would  have  been  transparent  to  ultra-violet  rays,  but  not  to 
Rontgen  rays.  There  is  only  the  supposition  left  that  the 
effect  was  produced  by  Rontgen  rays  or  something  that  comes 
with  Rontgen  rays." 

Upon  this  same  point  Thomson  *  has  offered  further  experi- 
ments. To  dispose  of  the  theory  that  x-ray  injuries  are  due 
to  electro-static  discharges,  he  repeated  the  experiment  of 
exposing  a  finger  to  x-rays,  using  for  it  the  adjoining  finger 
to  the  little  finger  upon  which  the  experiment  above  described 

*  American  X-ray  Journal,  1898,  iii,  p.  451. 
19 


290      CAUSE  OF  TISSUE-CHANGES    AFTER  X-RAY   EXPOSURES. 

was  performed.  The  experiment  was  as  follows:  ''The  adjoin- 
ing finger  (the  fourth  finger  of  the  left  hand)  was  protected 
by  sheet-lead  which  had  a  window  cut  in  it  so  as  to  limit  the 
effect  of  possible  burns  to  a  small  elongated  spot .  This  window 
in  the  sheet-lead  was  divided  by  a  strip  of  tinfoil  lying  close 
to  the  finger,  and  in  one  of  the  divisions  so  made  the  finger 
was  covered  by  a  double  layer  of  aluminum  foil,  the  other 
division  being  left  bare.  An  exposure  for  a  short  time  was 
followed  by  two  small  burns,  one  on  the  part  which  had  been 
under  the  aluminum  foil,  the  other  on  the  bare  spot.  It  is 
inconceivable  that  any  electro-static  effect  should  have  acted 
through  the  aluminum  alone  more  than  through  the  tinfoil, 
or  more  than  through  the  sheet-lead,  as  all  three  of  these  metal 
layers  were  in  electrical  contact  and  subjected  to  the  same 
conditions.  Electro-static  effect  or  electric  discharges  were 
plainly  ruled  out.  These  results  should  have  settled  the  ques- 
tion of  ozone,  chemical  effects,  electro-static  discharges,  etc." 

The  writer  has  carried  out  similar  experiments  on  guinea- 
pigs  as  follows:  The  guinea-pig  was  laid  upon  a  sheet  of  lead; 
the  anterior  third  of  the  trunk  and  head  were  protected  from 
x-rays  by  a  sheet  of  lead  -fa  of  an  inch  thick.  The  rest  of 
the  trunk  was  covered  by  a  sheet  of  aluminum  A-  of  an  inch 

•/  O  v 

thick.  All  three  sheets  were  in  electrical  contact  with  each 
other,  and  all  were  grounded  by  a  wire  having  a  water  con- 
nection. The  conditions  therefore  were  such  as  entirely  to 
exclude  any  electrical  effects,  and  also  to  protect  the  guinea- 
pig  from  any  rays  that  would  not  penetrate  aluminum  or 
lead.  The  guinea-pig  was  exposed  to  a  fairly  strong  light 
with  the  target  at  a  distance  of  five  inches,  for  an  hour  and 
a  half.  In  ten  days  the  hair  on  the  surface  which  was  covered 
by  aluminum  came  out,  and  an  x-ray  burn  developed.  The 
surface  protected  by  the  lead  was  entirely  unaffected.  A 
repetition  of  the  experiment  upon  another  guinea-pig  gave  the 
same  result. 

In  this  experiment  the  conditions  were  such  that  electrical 
effects  and  ultra-violet  light  wrere  plainly  thrown  out.  The 
entire  surface  was  covered  by  aluminum  or  lead,  which  were 
grounded,  thus  throwing  out  of  consideration  entirely  induced 


EFFECT    OF  ELECTRICAL    DISCHARGES.  291 

electrical  currents,  brush  discharges,  or  any  effects  in  the 
static  field.  The  entire  guinea-pig  was  covered  with  aluminum 
or  lead,  both  of  which  are  opaque  to  ultra-violet  rays,  thus 
excluding  them.  The  only  conclusion  that  can  be  drawn  from 
this  experiment,  as  from  Thomson's,  is  that  the  effect  could 
be  due  to  nothing  else  except  rays  of  energy  coming  from 
the  x-ray  tube,  which  were  able  to  penetrate  aluminum  and 
not  lead,  and  the  only  form  of  energy  having  these  qualities 
which  could  come  under  consideration  in  this  connection  is 
x-rays.  The  experiment  is  mathematically  conclusive,  and 
leaves  no  qualification  to  be  made  in  the  statement  that  x-ray 
burns  can  be  produced  by  x-rays  themselves. 

This  fact  docs  not  in  any  way  conflict  with  the  fact  that 
similar  effects  may  be  produced  by  high  tension  currents  without 
x-rays.  Schiff  and  Freund  *  have  called  attention  to  their 
experiments  proving  that  an  effect  similar  to  x-ray  effect  can 
be  produced  in  a  rabbit  by  direct  discharge  from  an  induction 
coil,  and  Rollins  f  has  reported  an  experiment  in  which  he 
exposed  his  hand  to  the  action  of  an  x-ray  tube,  the  resistance 
of  which  was  so  high  that  no  current  could  pass  through,  yet 
some  days  later  dermatitis  appeared  on  the  surface.  He  thinks 
that  this  proves  conclusively  that  burns  can  be  produced  by 
the  action  of  induced  electricity  around  the  tube,  but  he  very 
justly  adds  that  it  does  not  affect  the  proposition  that  x-rays 
themselves  can  cause  burns.  It  may  be  readily  admitted 
that  burns  similar  to  x-ray  burns  may  be  produced  by  electrical 
discharges;  indeed,  it  would  be  expected  a  priori  that  such 
effects  might  be  produced ;  but  that  does  not  in  any  way  affect 
the  fact  that  they  may  also  be  produced  by  x-rays.  That  the 
usual  burns  produced  in  x-ray  exposures  are  not  due  to  electrical 
discharges  is  shown  by  the  fact  that  when  lead  plates  are  used 
to  protect  the  surrounding  surfaces  the  burn  is  sharply  limited 
to  the  part  not  covered  by  lead.  I  have  had  innumerable 
opportunities  to  observe  this  fact,  and  I  have  never  seen  an 
x-ray  burn  extend  beyond  the  line  which  was  unprotected 
by  lead.  It  has  never  been  my  practice  to  ground  the  lead 

*Klin.  therap.  Wochenschr.,  1901,  Nos.  1,  2. 
t  Electrical  Review,  1898,  xxxii,  p.  12. 


292      CAUSE   OF  TISSUE-CHANGES   AFTER  X-RAY   EXPOSURES. 

mask,  and  the  fact  that  the  effect  upon  the  tissues  is  always 
sharply  limited  to  the  surface  which  the  x-rays  reach,  and 
does  not  appear  on  the  surface  covered  by  lead,  which  would 
not  in  any  way  interfere  with  effects  in  the  electro-static 
field,  shows  conclusively  that  the  electrical  effects  play  a  part 
of  no  practical  importance  in  the  production  of  these  burns. 
So  uniform  has  been  my  experience  in  this  connection  that 
I  have  no  hesitation  in  making  the  statement  without  qualifi- 
cation that  a  lead  plate  Tag-  of  an  inch  thick  will  absolutely 
prevent  the  development  of  any  burn  beneath  it.  One- 
sixteenth  inch  plate  is  specified  because  Rontgen  states  that 
lead  of  that  thickness  is  entirely  opaque  to  x-rays.  As  a  mat- 
ter of  fact,  a  lead  plate  ^  of  an  inch  thick  furnishes  ample 
protection  against  x-ray  burns. 

What  is  the  Property  in  X-rays  that  Affects  Tissues? — Accept- 
ing, then,  as  we  must,  that  the  changes  in  tissues  produced 
under  x-ray  exposures  are  due  to  the  x-rays  themselves,  what 
is  the  property  in  x-rays  that  causes  these  changes?  A  little 
consideration  of  the  subject,  I  believe,  leads  inevitably  to  the 
conclusion  that  it  is  actinic  properties  of  x-rays  which  are 
identical  with  or  very  closely  analogous  to  the  actinic  properties 
of  light.  A  consideration  of  the  analogous  properties  of  x-rays 
and  light  is  instructive  in  this  connection. 

It  is  the  accepted  viewr  among  physicists  to-day  that  x-rays 
are  a  form  of  radiant  energy  transmitted  through  the  ether 
of  the  same  character  as  light.  To  quote  Professor  Barker,* 
of  the  University  of  Pennsylvania :  ''Rontgen  himself  at  first 
was  favorably  inclined  to  the  idea  that  they  (Rontgen  rays) 
were  waves  due  to  longitudinal  vibrations  in  the  ether.  But 
later  he  was  convinced  that  they  were  essentially  identical 
with  light  waves — that  is,  with  transverse  waves  in  the  ether." 
The  obstacles  in  the  way  of  accepting  the  theory  that  x-rays 
were  transverse  wraves  in  the  ether  were  largely  due  to  the 
fact  that  they  did  not  act  in  the  same  way  as  light  waves, 
as  regards  reflection,  refraction,  and  diffraction.  These  obstacles 
were  overcome  by  the  idea  which  was  suggested  about  the 

*  Preface  to  "Rontgen  Rays,"  edited  by  Barker,  Harper  Bros.,  New  York, 
1899. 


NATURE  OF  X-RAYS.  293 

same  time  by  Professor  Stokes,  of  Cambridge,  Professor  J.  J. 
Thompson,  of  Cambridge,  and  Professor  Lehman,  of  Karlsruhe, 
that  x-rays  are  due  to  quite  irregular  pulses  and  their  phenomena 
are  quite  different  on  that  account  from  those  of  regular  trains 
of  waves,  like  light.  This  idea  was  very  beautifully  set  forth 
by  Professor  Stokes  in  the  Wilde  Lecture.*  He  says:  "  Accord- 
ing to  the  theory  of  the  nature  of  the  Rontgen  rays  which 
I  have  endeavored  very  briefly  to  bring  before  you,  we  have 
here,  as  I  think,  a  system  various  parts  of  which  fit  into  one 
another.  You  start  with  Rontgen  rays,  which  consist,  as  I 
conceive,  of  an  enormous  succession  of  independent  pulses; 
you  pass  to  the  Becquerel  rays,f  which  are  still  irregular,  but 
are  beginning  to  have  a  certain  amount  of  regularity,  and  you  end 
with  the  rays  which  constitute  ordinary  light.  According  to 
this  theory,  the  absence  of  diffraction  in  the  Rontgen  ray  is 
explained,  not  by  supposing  they  are  rays  of  light  of  excessively 
short  wave  length,  but  by  supposing  they  are  due  to  an  irregular 
repetition  of  isolated  and  independent  disturbances." 

X-rays,  then,  and  light  rays  are  transverse  vibrations  of  the 
ether  of  essentially  identical  character,  differing  only  in  unes- 
sential variations  in  the  quality  of  the  waves.  This  concep- 
tion entirely  disposes  of  the  difficulties  in  the  way  of  the 
theory  that  x-rays  and  light  rays  are  modes  of  motion  of  the 
ether  of  essentially  the  same  character. 

The  physical  resemblance  between '  x-rays  and  light  is  very 
close.  X-rays  are  by  no  means  all  of  one  character,  but  consist 
of  "a  mixture  of  rays  which  are  absorbed  in  different  degrees 
and  which  have  different  intensities."  J  It  is  agreed  that  x-rays 
vary  in  their  property  of  affecting  tissues.  In  these  respects 

*  "Rontgen  Rays,"  Barker,  p.  63. 

f  In  considering  the  relationship  of  x-rays,  Becquerel  rays,  and  light,  it  is  in- 
teresting to  note  that  effects  on  tissues  similar  to  those  produced  by  x-rays  have 
been  produced  by  Becquerel  rays.  Becquerel  (Conipt.  rend.  Acad.  Sci.,  1901, 
cxxxii,  p.  1289)  produced  an  ulcer  on  his  own  person  by  wearing  a  small  flask  of 
radium  near  the  skin.  Danlos  (Annales  de  Derm.  u.  Syph.,  1902,  4e  Serie,  iii, 
p.  723)  has  reported  cures  of  lupus  by  exposures  to  Becquerel  rays,  the  results 
being  entirely  similar  to  those  produced  by  x-rays.  Such  results  as  the  above 
furnish  the  strongest  possible  evidence  of  the  essential  relationship  between  these 
different  forms  of  energy. 

J  Rontgen's  third  article,  "  Rontgen  Rays, "  Barker,  p.  35. 


294      CAUSE  OF  TISSUE-CHANGES  AFTER    X-RAY  EXPOSURES. 

the  analogy  to  light  is  as  close  as  possible.  Light  consists  of 
a  mixture  of  rays,  extending  from  the  rays  beyond  the  red 
to  those  beyond  the  violet,  and  these  differ  in  their  actinic 
properties,  from  the  rays  at  the  red  end  of  the  spectrum,  which 
practically  have  no  actinic  properties,  to  the  highly  actinic 
rays  at  the  violet  end  of  the  spectrum. 

X-rays  and'  light  rays  have  the  common  property  of  causing 
fluorescence  in  certain  substances.  An  interesting  analogy 
in  the  way  of  fluorescence  exists  between  the  ultra-violet  rays 
which  are  invisible  and  the  x-rays  which  are  also  invisible. 
Invisible  ultra-violet  rays  are  converted  into  visible  blue  rays 
on  impinging  upon  the  surface  of  quinin  in  solution,*  and 
Rontgen  rays  are  converted  into  visible  greenish  rays  on 
impinging  upon  the  surface  of  barium  platino-cyanide.  In 
other  words,  both  x-rays  and  ultra-violet  rays  are  convertible 
into  visible  light  rays. 

As  is  well  known,  the  active  properties  of  light  and  of  x-rays, 
as  shown  in  their  action  upon  silver  salts,  are  the  same.  So 
exactly  are  they  identical  that  the  methods  of  photograph}' 
with  light  are  used  with  x-rays,  without  variation  either  in 
the  preparation  of  the  plates  or  their  development  after  ex- 
posure. The  action  of  the  one  upon  the  silver  salts  is  identical 
with  that  of  the  other.  This  subject  has  been  carefully  studied 
by  A.  and  L.  Lumiere  f  and  by  Hansmann.  J  They  agree  that 
the  chemical  changes  in  photographic  emulsions  produced  by 
light  and  those  produced  by  x-rays  are  identical. 

As  we  have  already  seen,  the  effects  of  light,  as  shown  by 
sunburn,  and  of  x-rays,  as  shown  by  x-ray  burns  of  mild  intensity, 
are  indistinguishable  in  appearance.  There  is  the  same  tanning 
and  the  same  redness  in  x-ray  dermatitis  as  in  sunburn.  And 
as  Finsen  has  shown,  light  burns  also  have  a  period  of  incubation 
extending  over  one  or  two  days.  How  close  the  clinical  resem- 
blance is  between  sunburn  and  mild  x-ray  burns  has  been 
shown  when  considering  x-ray  burns.  § 

*  "  Radiography, "  Bottone,  Whittaker  &  Co.,  London,  1898,  p.  160. 
tCompt.  rend.  Acad.  Sci.,  1896,  cxxii,  p.  382. 
t  Fortschr.  a.  d.  Geb.  der  Rontgenstrahlen,  1902,  v,  p.  89. 
\  In  comparing  the  effect  of  x-rays  and  light  upon  the  skin,  it  is  interesting  to 
consider  some  of  Finsen's  experiments  upon  the  subject.     He  exposed  the  flexor 


SIMILARITY   OF  X-RAYS    AND   LIGHT.  295 

But  outside  of  all  other  considerations  we  have  one  fact 
in  the  effect  of  x-rays  upon  the  organs  of  sight  which  is  the 
strongest  possible  presumptive  evidence  that  x-rays  are  a 
form  of  energy  of  the  closest  similarity  in  character  to  light; 
and  that  is  the  fact  that  x-rays  can  produce  a  light  sensation 
upon  the  retina.  The  statement  of  Professor  Rontgen  *  upon 
this  highly  interesting  point  is  as  follows:  "The  fact  observed 
by  Herr  G.  Brandes,  that  the  x-rays  can  produce  a  light  sensa- 
tion on  the  retina  of  the  eye,  I  have  found  confirmed.  There 
stands  also  in  my  observation  journal  a  note  at  the  beginning 
of  the  month  of  November,  1895,  according  to  which  I  per- 
ceived a  feeble  light  sensation,  which  spread  over  the  whole 
field  of  vision,  when  I  was  in  an  entirely  darkened  room,  near 
a  wooden  door  on  the  other  side  of  which  there  was  a  Hittorf 
tube,  whenever  discharges  were  sent  through  the  tube.  Since 
I  observed  this  phenomenon  only  once,  I  thought  it  a  subjective 
one,  and  the  fact  that  I  never  saw  it  repeated  is  because 
later,  instead  of  a  Hittorf  tube,  other  apparatus  was  used, 

surface  of  the  forearm  for  twenty  minutes  to  a  very  powerful  electric  arc  light 
(80-ampere  light)  at  50  to  75  cm.  distance.  There  occurred  an  inflammation  of 
the  skin  which  he  describes  as  follows  : 

"The  inflammation  thus  incited  differs  from  any  other  kind  of  inflammation 
of  the  same  extent,  inasmuch  as  it  was  followed  by  a  marked  pigmentation  of 
the  skin  of  several  months'  duration. 

"  It  does  not  appear  at  once,  as  does  a  burn,  but  has  its  maximum  in  one  or 
two  days  after  exposure. 

"It  appears  only  on  those  parts  of  the  skin  which  have  been  directly  exposed 
to  the  light,  while  heat  rays  are  also  capable  of  acting  through  the  clothing." 

Several  months  afterward  all  traces  of  the  burn  had  disappeared.  Finsen 
was  able  to  demonstrate  that  the  skin  still  showed  traces  of  the  effect  of  light,  in 
that  parts  which  had  been  protected  remained  almost  white  on  rubbing,  while 
the  parts  which  had  been  exposed  to  the  light  were  markedly  flushed.  He  adds 
that  this  can  be  explained  only  by  assuming  that  the  action  of  the  chemical  rays 
had  caused  a  more  or  less  permanent  dilatation  of  the  capillaries  and  smaller 
arterioles  of  the  skin. 

It  is  thus  seen  that  experimental  inflammations  of  the  skin  produced  by  ex- 
posures to  light  show  effects  strikingly  analogous  to  those  of  ar-rays.  The  mac- 
roscopic changes  are  similar,  there  is  a  period  of  incubation,  and  the  effects  per- 
sist for  a  long  time Abstract  from  Clemensen's  report  of  Finsen's 

article,  "  Nye  Undersoegelser  over  Lysets  Indvirkning  paa  Huden."  Meddel- 
elser  fra  Finsen's  Medicinske  Lyssinstitut,  January,  1900,  pp.  17-18  ;  Chicago 
Medical  Recorder,  1902,  xxiii,  p.  195. 

*  "  Rontgen  Rays,"  Barker,  p.  39. 


296      CAUSE  OF  TISSUE-CHANGES  AFTER    X-RAY  EXPOSURES. 

not  exhausted  so  much  and  not  provided  with  platinum  anodes. 
On  account  of  their  state  of  high  exhaustion,  Hittorf  tubes 
furnish  rays  which  are  only  slightly  absorbed;  and  on  account 
of  the  presence  of  a  platinum  anode,  which  is  struck  by  the 
cathode  rays,  they  furnish  intense  rays,  a  condition  which 
is  favorable  to  the  production  of  the  light  phenomenon  referred 
to.  I  was  obliged  to  replace  the  Hittorf  tubes  by  others, 
because  after  a  very  short  while  all  were  perforated.  With 
the  hard  tubes  now  in  general  use  the  experiment  of  Brandes 
may  be  easily  repeated." 

This  demonstration  that  x-rays  will  produce  upon  the  organs 
of  sight  a  light  sensation  is  of  the  highest  possible  significance 
in  arriving  at  an  interpretation  of  the  effect  of  x-rays  upon 
living  cells.  To  put  it  in  other  words,  it  means  that  x-rays 
have  the  property  of  influencing,  as  though  they  were  light 
rays,  the  organs  which  have  been  especially  adapted  to  the 
reception  of  impressions  from  the  form  of  energy  which  we 
know  as  light.  Stronger  evidence  could  hardly  be  found  that 
the  effects  of  x-rays  and  of  light  rays  upon  living  cells  are  as 
close  as  possible. 

We  have,  then,  the  following  facts :  x-rays  and  light  are  forms 
of  vibration  of  the  ether  of  the  same  kind.  Arrays  and  the 
highly  actinic  ultra-violet  rays,  both  of  which  are  invisible, 
are  both  capable  of  producing  fluorescence  in  certain  sub- 
stances, and  thus  being  converted  into  visible  light  rays.  The 
actions  of  light  and  of  x-rays  upon  salts  sensitive  to  light  are 
the  same;  the  actions  of  light  and  of  x-rays  upon  the  skin 
and  subcutaneous  tissues  are  the  same;  and,  finally,  x-rays 
produce  upon  the  retina  a  sensation  of  light. 

The  resemblances,  therefore,  between  x-rays  and  light  are 
as  close  as  possible,  and  the  inference  could  not  be  more  direct 
that  the  property  in  x-rays  which  causes  effects  upon  silver 
salts  and  upon  tissues  is  identical  with,  or  as  closely  analogous 
as  possible  to,  the  property  in  light  which  causes  the  same 
effects  upon  silver  salts  and  upon  living  tissues.  Now,  it  is 
universally  accepted  that  the  effect  of  light  upon  salts  which 
are  susceptible  to  light,  as  certain  silver  salts,  and  upon  the 
skin,  is  attributable  to  the  actinic  properties  of  light.  It 


EFFECTS   OF   ACTINIC   PROPERTIES   OF   X-RAYS.  297 

seems  impossible,  then,  to  avoid  the  conclusion  that  the  effect 
of  x-rays  upon  the  same  salts  and  upon  living  tissues  is  due 
to  the  actinic  properties  of  x-rays.  In  other  words,  the  property 
of  x-rays  that  causes  reduction  of  silver  salts  in  a  photographic 
emulsion  is  the  same  property  which  causes  the  effect  upon 
living  tissues. 

And  this  labored  analysis  of  the  question  leads  us  to  the 
same  conclusion  that,  it  would  seem,  would  be  most  natural 
upon  first  glance.  For,  without  analysis,  it  would  seem  rea- 
sonable to  conclude  that  the  property  of  x-rays  that  causes 
rearrangement  of  the  molecules  of  a  silver  salt  and  the  formation 
of  a  new  compound  is  the  same  that  affects  the  cellular  mechan- 
ism of  a  tissue  cell  and  causes  rearrangement  of  the  intra- 
cellular  structure. 

The  proposition  that  the  effects  of  x-rays  upon  tissues  are 
due  to  their  actinic  properties,  just  as  the  effects  of  light  rays 
upon  tissues  are  due  to  their  actinic  properties,  does  not  carry 
with  it  the  corollary  that  the  actinic  properties  of  light  and 
of  x-rays  are  identical.  The  actinic  properties  of  the  two 
are  very  strikingly  analogous;  they  may  be  identical,  but  that 
they  are  identical  in  every  respect  is  not  proved,  and  is  not  a 
necessary  inference  from  their  similar  qualities.  And,  on  the 
other  hand,  the  establishment  of  certain  dissimilar  qualities 
does  not  in  any  way  destroy  the  force  of  the  analogy.  They 
may  have  certain  characteristics  quite  dissimilar,  without 
interfering  with  the  inference  that  they  are  in  their  essential 
nature  the  same,  just  as  the  fact  that  x-rays  cannot  be  diffracted, 
reflected,  or  refracted,  offers  no  obstacle  to  the  theory  that 
x-rays  and  light  are  forms  of  energy  of  essentially  the  same 
nature. 

What  are  the  processes  set  in  motion  in  the  living  cells  when 
they  are  changed  by  x-rays  or  light?  That  question  no  man 
can  answer  now,  nor  ever  can  until  we  know  what  the  changes 
are  in  the  cell  that  constitute  life.  As  to  how  x-rays  or  light  may 
act  to  cause  these  processes  to  be  set  in  motion,  a  theoretical 
answer  to  that  question  is  not  difficult  to  formulate.  P.  M. 
Jones,*  of  San  Francisco,  has  stated  it  very  clearly  as  follows: 

*Phila.  Med.  Jour.,  1900,  v,  p.  63. 


298      CAUSE   OF  TISSUE-CHANGES  AFTER   X-RAY  EXPOSURES. 

"The  treatment  of  lupus  by  exposures  to  x-rays  is  akin  to 
the  treatment  by  exposures  to  ultra-violet  light  (Finsen),  and 
to  the  treatment  by  exposure  to  concentrated  light  (Abrams). 
In  each  case  the  action  seems  to  be  a  simple  one,  and  the  explana- 
tion not  far  to  seek.  The  pathologic  tissue  is  largely  composed 
of  very  complex  and  unstable  molecules,  which  collectively 
make  up  the  cell-structure  of  the  lesion.  As  we  know,  com- 
paratively little  energy  is  required  to  upset  these  complex 
molecules  and  cause  a  rearrangement  of  their  atoms,  thus 
producing  a  very  different  cell,  with  a  consequent  modification 
of  the  cell,  if  not  its  actual  death.  In  the  action  of  sunlight 
upon  the  skin  (burn,  tan,  freckles,  etc.)  we  have  excellent 
illustrations  of  capability  of  radiant  energy  to  produce  these 
chemical  rearrangements.  As  the  rays  from  a  soft  tube,  which 
are  more  easily  absorbed  by  the  skin,  or  any  body  first  en- 
countered, than  are  those  from  a  'hard'  tube,  are  found  to 
produce  the  so-called  dermatitis  Rontgenii  more  readily  than 
the  rays  from  a  hard  tube,  so  they  are  more  efficacious  in  the 
treatment  of  lupus.  It  is  simply  that  such  rays  of  compara- 
tively long  wave  length  are  absorbed  and  part  with  their  radiant 
energy,  while  rays  of  shorter  wave  length,  less  readily  absorbed, 
do  not  to  any  great  extent  affect  the  chemical  arrangement 
of  the  cells  in  the  superficial  tissues.  I  believe,  for  the  reasons 
just  given,  that  the  method  of  treatment  by  ultra-violet  light 
(Finsen)  will  be  found  to  be  quicker  and  better  than  the  treat- 
ment by  x-rays.  In  comparison  with  the  x-rays  the  ultra- 
violet rays  from  an  arc  light  have  a  very  long  wave  length, 
and  hence  will  part  with  all  their  energy  through  absorption 
by  the  molecules  of  the  superficial  cells.  The  action  is  a  purely 
mechanical  one,  a  transfer  of  energy  by  wave  motion  (radiant 
energy),  and  is  typically  illustrated  by  the  change  which  occurs 
in  the  photographic  emulsion  when  exposed  to  light." 

Several  objections  have  been  offered  to  the  idea  that  the 
effects  of  x-rays  and  of  light  on  tissues  are  of  the  same  character. 
In  the  first  place,  while  the  lesser  degrees  of  x-ray  burns  are 
like  sunburn,  light  does  not  cause  destructive  lesions  like 
the  severe  x-ray  burns.  This  may  be  explained  upon  several 
suppositions:  In  the  first  place,  the  tissues  may  be  more  sus- 


DIFFERENCES    IN    EFFECTS   OF   X-RAYS   AND    LIGHT.          299 

ceptible  to  the  actinic  properties  of  x-rays  than  to  those  of 
light.  Or,  to  express  it  in  other  words,  the  actinic  properties, 
as  respects  living  cells,  of  a  given  quantity  of  energy  in  the  form 
of  x-rays  may  be  greater  than  of  an  equal  quantity  of  energy  in 
the  form  of  light  rays.  Or  it  may  be  that  the  actinic  energy  in  the 
x-rays  that  can  be  projected  from  a  powerfully  energized  tube 
upon  a  given  surface  is  greater  in  quantity  that  can  be  obtained 
from  the  amount  of  light  that  it  is  practicable  to  focus  upon 
any  part  of  the  body.  It  is  possible  that  both  of  these  factors 
play  a  part.  To  consider  the  second  point  first,  it  is  possible 
that  if  we  concentrated  a  sufficient  quantity  of  light  upon  a 
given  area,  effects  quite  equal  in  severity  to  those  of  a  severe 
x-ray  burn  might  be  produced.  And  as  regards  the  first  point 
there  is  nothing  difficult  in  supposing  that  the  actinic  proper- 
ties of  x-rays  are  more  powerful  than  those  of  any  of  the 
rays  of  light.  The  different  rays  of  light  themselves  vary  in 
their  actinic  properties,  from  the  red  and  ultra-red  rays  with 
almost  no  actinic  properties,  to  the  highly  actinic  rays  at  the 
violet  end  of  the  spectrum.  If  light  rays  vary  so  much  among 
themselves,  as  regards  the  intensity  of  their  actinic  properties, 
is  it  hard  to  imagine  that  there  might  be  a  variation  in  the 
same  respect  between  light  rays  and  x-rays? 

Again,  the  absence  of  deep  destructive  processes  from  sunburn 
may  be  explained  by  the  lesser  penetration  of  light  rays.  That 
light  rays  can  destroy  living  tissue  is  proved  when  the  epidermis 
is  destroyed  in  sunburn,  and  it  is  entirely  logical  to  suppose 
that  could  they  penetrate  the  tissues  in  sufficient  quantities, 
they  might  exert  a  similar  destructive  influence  upon  deeper 
tissues. 

Another  reason  offered  for  not  accepting  the  opinion  that 
actinic  properties  of  x-rays  similar  to  the  active  properties 
of  light  are  the  explanation  of  x-ray  effects  on  tissues,  is  the 
difference  in  the  effect  of  x-rays  and  of  light  upon  bacteria. 
It  must  be  accepted  that  x-rays  have  less  germicidal  power 
than  has  ultra-violet  light. 

Numerous  articles  have  been  published  upon  the  question 
of  the  effect  of  light  upon  bacteria.  Their  general  tenor  is  to 
the  effect  that  light  has  a  distinct  inhibitory  effect  upon  the 


300      CAUSE  OF  TISSUE-CHANGES  AFTER   X-RAY  EXPOSURES. 

growth  of  bacteria,  but  that  this  effect  varies  in  different  bac- 
teria, under  different  conditions  of  growth,  and  under  various 
other  circumstances.  Most  of  the  experiments  which  have  been 
made  have  not  been  conducted  under  sufficiently  exact  conditions 
to  give  their  conclusions  great  weight.  In  the  \vords  of  Dr. 
Bang,  of  the  Finsen  Laboratories:  "The  results  obtained  by 
different  investigators  do  not  compare  with  the  amount  of  work 
done.  .  .  .  One  gets  the  impression  from  most  of  these 
researches  that  they  have  been  done  by  more  or  less  skilful 
bacteriologists,  but  by  very  poor  physicists." 

Perhaps  the  most  exact  experiments  which  have  been  made 
are  those  by  Downes  and  Blunt,  and  by  Finsen  and  his  associ- 
ates. Downes  and  Blunt  *  conclude  from  their  investigation 
that  light  is  inimical  to  the  growth  of  bacteria,  and  under  favor- 
able circumstances  wholly  prevents  it.  This  action  is  nearly 
confined  to  the  light  at  the  blue  end  of  the  spectrum.  If  the 
germicidal  properties  of  light  be  represented  graphically  by  a 
curve,  the  high  point  occurs  at  the  violet  end  of  the  spectrum, 
sinking  rapidly  between  the  blue  and  the  green,  there  being 
still  some  effect  produced  by  the  red  rays.  They  made  a  very 
important  additional  observation  that  this  effect  of  light  is  in 
proportion  to  the  amount  of  free  oxygen  in  the  culture-medium. 
Experiments  with  organisms  in  tubes  from  which  the  oxygen 
had  been  exhausted  showed  no  difference  in  growth  between  the 
control  tubes  and  those  exposed  to  light.  This  would  seem  to 
indicate  that  the  effect  here  is  not  that  of  light  per  se,  and  offers 
some  analogy  to  the  fact  that  x-rays  have  no  effect  upon  bacteria 
in  cultures,  but  a  decided  effect  upon  bacteria  in  living  tissues. 

Larsen,  in  the  publications  of  the  Finsen  Institute,!  has 
found,  first:  "That  different  bacteria  are  differently  affected  by 
light,  and  that  there  is  considerable  difference  in  the  resistance 
of  even  closely  related  varieties";  and,  second:  "That  the  time 
which  light  requires  to  kill  certain  species  of  bacteria  bears  no 
constant  relation  to  that  needed  to  impair  their  growth." 

Buchner  J   has   made  experiments    upon    numerous   bacilli : 

*  Proceedings  of  the  Royal  Society,  1896,  vol.  xxviii,  p.  199. 

t  Quoted  by  Clemensen,  Chicago  Medical  Recorder,  1902,  xxiii,  p.  195. 

J  Arch.  f.  Hygiene,  1893,  xvii,  p.  179. 


EFFECTS    OF    LIGHT    AND    X-RAYS   ON    BACTERIA.  301 

Bacillus  typhosus,  Bacillus  coli,  Bacillus  pyocyaneus,  and  others. 
His  experiments  also  show  the  germicidal  effect  of  light  upon  bac- 
teria in  cultures.  As  to  the  relative  germicidal  properties  of  the 
rays,  he  came  to  this  interesting  conclusion,  in  the  course  of  his 
experiments:  " It  gradually  became  evident  that  the  develop- 
ment of  typhoid  bacilli  was  not  at  all  prevented  by  exposure 
to  orange,  red,  ultra-red,  or  also  (contrary  to  expectations) 
ultra-violet  light;  while  the  clearest  part  of :  the  spectrum, 
green,  blue,  and  to  a  certain  extent  violet  light,  acted  in  such  a 
way  as  to  prevent  the  development  and  to  kill  the  organism." 

It  will  be  observed  that  these  investigations  as  to  the  effect  of 
light  upon  bacteria  do  not  offer  findings  upon  which  a  very  strong 
argument  can  be  made  for  an  essential  difference  between  x-rays 
and  light  rays.  Light  rays  require  the  presence  of  oxygen  to 
destroy  bacteria,  and  the  different  light  rays  vary  greatly  in  their 
actinic  properties.  Bacteria  vary  considerably  in  their  re- 
sistance to  light,  and  doubtless  certain  bacteria  are  wholly 
unaffected  by  it.  The  most  significant  fact  in  this  connection 
is  the  observation  of  Buchner  that  the  rays  of  greatest  germicidal 
properties,  at  least  as  regards  the  typhoid  bacillus,  are  those 
around  the  blue  line  of  the  spectrum,  which  have  a  stronger 
germicidal  property  than  the  ultra-violet  rays.  In  other  words, 
according  to  Buchner 's  findings,  the  germicidal  properties  of 
light  rays  do  not  correspond  entirely  to  their  actinic  properties. 
Considering  all  these  facts, — that  while  light  rays  are  germicidal 
to  certain  bacteria  they  are  not  to  others;  that  they  are  not 
germicidal  per  se;  that  the  different  rays  of  light  vary  in  their 
germicidal  properties;  and,  what  is  most  significant  of  all,  that 
the  rays  of  highest  germicidal  properties  are  not  always  the  rays 
of  highest  actinic  properties, — there  seems  little  ground  for  the 
assumption  that  x-rays  and  light  rays  differ  essentially  because 
they  do  not  correspond  in  their  effects  on  bacteria.  The  same 
argument  could  be  used  to  prove  that  rays  of  light  in  different 
parts  of  the  spectrum  were  essentially  different  forms  of  energy. 

Indeed,  the  differences  between  the  actinic  properties  of  light 
and  of  x-rays  are  so  few,  and  so  easily  reconciled,  that  their 
existence  is  not  to  be  wondered  at,  but  it  is  rather  a  source  of 
wonder  that  there  should  not  be  more. 


CHAPTER  V. 

THE  TECHNIQUE  OF  X-RAY  EXPOSURES  FOR 
THERAPEUTIC  PURPOSES. 

THE  central  idea  in  every  method  of  using  x-rays  for  thera- 
peutic purposes  is  to  so  use  the  agent  as  to  get  a  sufficient 
effect  while  reducing  to  a  minimum  the  risk  of  producing  x-ray 
burns  of  severe  character.  Different  workers  go  about  attaining 
this  end  in  different  ways,  and  in  taking  up  this  subject  it 
may  be  well  to  consider  first  the  technique  of  some  of  the 
workers  in  this  field.  As  a  preliminary  to  this,  however,  it 
should  be  said  that  it  is  extremely  difficult  from  any  description 
to  arrive  at  the  writer's  technique,  for  the  reason  that  there 
are  so  many  factors  that  come  into  play  in  determining  the 
intensity  and  the  quality  of  the  rays,  the  two  points  of  prime 
importance  in  every  technique.  In  case  a  coil  is  used,  the 
size  of  the  coil,  the  way  it  is  wound,  the  amount  of  the  primary 
current  that  is  used  to  energize  it,  are  all  questions  having 
bearing  upon  the  character  of  the  x-rays  which  are  produced. 
If  a  static  machine,  similar  questions  arise  as  to  its  size,  its 
speed,  etc.  In  addition,  there  come  into  question  the  distance 
of  the  target  from  the  exposed  surface,  the  length  of  exposures, 
the  frequency  of  exposures,  and,  last  and  most  important 
of  all,  and  far  and  away  most  difficult  to  determine,  the  quality 
of  the  tube  used.  These  varying  factors  render  the  personal 
judgment  of  the  observer  a  very  important  matter  in  any 
technique,  and  that  is  a  thing  which  cannot  be  determined 
from  a  description.  On  account  of  these  difficulties,  no  worker, 
as  far  as  I  know,  has  yet  given  an  adequate  description  of  his 
technique.  Numerous  workers,  however,  have  given  descrip- 
tions of  their  techniques  sufficiently  definite  for  one  to  arrive 
at  the  general  plans  which  they  pursue,  and  a  consideration, 
as  far  as  possible,  of  these  various  plans  of  procedure  is  valuable. 

Kienbock's    Technique. — As  a    general    custom    the  various 

302 


KIENBOCK'S  TECHNIQUE.  303 

workers  assume  that  there  is  a  variation  in  the  susceptibility 
of  different  individuals,  and  largely  on  account  of  this  they 
feel  their  way  along,  as  it  were,  until  they  determine  the  limits 
of  safety  in  the  treatment  of  each  patient.  The  most  radical 
exception  to  this  plan  of  treatment  is  that  advocated  by  Kien- 
bock.*  Kienbock  puts  down  as  a  postulate  that  there  is  no 
such  thing  as  idiosyncrasy  to  x-rays,  and  that  what  is  safe 
for  one  patient  is  safe  for  another.  Accordingly  he  pursues  a 
daring  plan  of  treatment.  He  advises  a  coil  of  20  to  30  cm. 
spark  length,  connected  with  a  lighting  circuit,  an  interrupter 
giving  from  1200  to  2400  interruptions  per  minute,  and  regu- 
lating x-ray  tubes.  He  uses  a  medium  soft  tube,  which  he 
places  at  a  distance  of  15  to  20  cm.  from  the  surface  to  be 
treated.  The  surrounding  surface  he  protects  with  sheet-lead 
0.5  mm.  thick,  under  which  he  places  a  flannel  strip  to  protect 
the  skin  from  sparks.  He  uses  a  tube  which  is  capable  of  pro- 
ducing a  good  picture  of  the  thorax  of  a  medium-sized  man, 
when  viewed  through  a  fluoroscope  at  a  distance  of  60  cm. 
from  the  focus,  and  he  uses  enough  light  to  make  a  skiagram 
(he  does  not  say  of  what,  but  presumably  of  the  thorax)  with 
an  exposure  of  thirty  seconds.  If  the  thorax  is  meant,  that 
is  a  very  intense  light.  With  this  standard  amount  of  x-rays 
he  gives  exposures  of  from  five  to  twenty  minutes.  What  he 
calls  a  " normal  exposure"  is  an  exposure  given  with  such 
an  equipment  and  under  such  conditions,  and  of  twenty  min- 
utes' duration.  "Such  an  exposure  will  have  the  following 
results:  On  normal  skin,  after  a  period  of  latency  of  fourteen 
days,  the  hair  will  fall  out,  accompanied  by  an  erythema  lasting 
a  few  days.  On  skin  affected  with  sycosis  the  loss  of  hair 
will  occur  as  early  as  the  eighth  day,  accompanied  by  the 
formation  of  numerous  pustules.  Lupous  tissue  will  become 
exfoliated  after  a  lapse  of  a  week."  He  states  that  the  effect 
of  a  normal  exposure  of  twenty  minutes  may  be  produced 
by  dividing  the  action  of  the  radiance  over  several  sittings 
of  shorter  duration,  and  he  accordingly  formulates  three  methods 
of  x-ray  therapy.  "First:  daily  sittings  with  a  radiance  of 
slight  intensity,  continued  until  the  first  symptoms  of  reaction 

*  Interstate  Med.  Jour.,  1902,  ix,  pp.  1,  60. 


304  TECHNIQUE    FOR    X-RAY   THERAPEUTICS. 

appear.  Second:  (a)  sittings  with  a  radiance  of  medium  in- 
tensity twice  a  week  until  reaction  begins  to  be  manifest  (about 
two  weeks);  or  (6)  three  or  four  sittings  with  a  radiance  of 
medium  intensity,  given  on  alternate  days.  Or,  third:  the 
normal  exposure  in  a  single  sitting  and  await  reaction. 

''Treatment  by  any  of  these  methods  is  appropriate  and 
conforms  to  the  fundamental  principles  laid  down  above.  The 
second  is  the  method  to  be  preferred,  inasmuch  as  the  first 
is  tedious  for  both  patient  and  physician  and  the  third  demands 
a  certain  experience  on  the  part  of  the  operator.  After  the 
first  sign  of  reaction  appears  we  deem  it  advisable  to  await 
the  termination  of  the  characteristic  inflammatory  process, 
and  then  if  necessary  repeat  the  exposure.  If,  in  using  the 
second  and  third  methods,  absolutely  no  reaction  occurs  at 
the  end  of  three  weeks,  we  may  feel  justified  in  repeating  the 
normal  exposure.  If,  however,  a  mild  reaction,  non-progressive 
in  character,  has  taken  place,  an  additional  exposure  less  than 
normal  can  be  applied.  As  stated  above,  the  second  normal 
exposure  is  made  after  the  subsidence  of  the  inflammatory 
reaction  excited  by  the  first.  Thus  this  treatment  may  involve, 
in  accordance  with  the  nature  of  the  case,  repetitions  of  x-ray 
applications  extending  over  months  or  even  years." 

It  will  be  observed  from  his  description  that  Kienbock 
uses  a  light  of  very  decided  intensity,  with  which,  he  states, 
an  experienced  operator  can  give  an  exposure  of  twenty 
minutes  at  a  distance  of  15  cm.  without  any  attention  to  the 
particular  susceptibility  of  the  individual.  And  he  then  de- 
scribes a  definite  set  of  reactions  which  will  follow  such  a  "nor- 
mal exposure."  I  do  not  believe  any  hard  and  fast  description, 
such  as  he  attempts,  of  the  reaction  which  will  follow  a  definite 
exposure  can  be  accepted.  Assuming  that  he  can  make  his 
light  of  a  definite  intensity  under  all  circumstances,  which 
surely  cannot  be  done,  all  individuals  will  not  react  to  the 
same  extent.  His  second  and  third  methods  are  to  my  mind 
dangerous,  and  they  cannot  be  carried  out  with  safety  in  all 
cases.  His  first  method  does  not  differ  in  any  essential  particu- 
lar from  the  plan  of  various  other  workers. 

The   fundamental   fact  upon  which  Kienbock 's  technique  is 


SCHOLTZ?S   TECHNIQUE.  305 

based  is  that  there  is  no  variation  worthy  of  consideration 
in  the  susceptibility  of  individuals  to  z-rays.  I  have  previously 
given  my  reasons  for  dissenting  entirely  from  this  statement, 
and  Kienbock  himself  leaves  out  of  consideration  in  his  tech- 
nique certain  variations  in  susceptibility  which  he  himself 
thinks  he  has  found  in  patients — namely,  differences  in  sus- 
ceptibility of  different  parts  of  the  body,  of  healthy  and  diseased 
parts,  and  of  young  and  older  individuals.  Perhaps  in  the 
hands  of  a  very  experienced  x-ray  worker  such  a  plan  of  treat- 
ment as  Kienbock 's  may  be  carried  out  with  reasonable  safety, 
but  it  requires  great  experience  and  unusual  judgment,  and 
even  under  the  most  favorable  circumstances  contains,  I  am 
sure,  elements  of  grave  danger. 

Scholtz's  Technique. — Scholtz  *  recommends  a  plan  of  treat- 
ment somewhat  after  Kienbock 's  plan.  "After  a  light  pre- 
liminary exposure  is  given  (a  precaution  especially  necessary 
in  acne,  hypertrichosis,  folliculitis  barbsc,  and  eczema),  in 
order  to  determine  the  condition  of  the  skin,  after  a  few  days 
a  relatively  strong  exposure  is  given,  so  as  to  produce  as  soon 
as  possible  in  the  area  the  desired  amount  of  reaction.  Then 
the  intensity  of  exposure  is  at  once  decreased.  The  later  light 
exposures  are  continued  to  the  point  of  getting  the  desired 
effect:  for  example,  epilation.  This  procedure  avoids  the  two 
extremes,  of  bringing  about  an  undesired  reaction,  and  of 
continuing  perhaps  for  weeks  insufficient  treatment,  being 
similar  to  that  employed  in  using  a  drug  of  slow  and  cumulative 
effect.  For  example,  desiring  to  cause  a  falling  of  the  hair 
of  the  head,  in  the  case  of  favus,  a  first  exposure  is  given  of 
fifteen  minutes  at  30  cm.  Then,  in  three  or  four  days,  exposures 
every  other  day  of  fifteen  minutes;  later  every  third  day,  three 
or  four  minutes." 

For  large  surfaces  he  advises  a  distance  of  30  to  40  cm., 
and  for  small  surfaces  a  distance  of  10  to  15  cm.  The  tube 
used  should  be  medium  hard,  of  large  volume,  and  provided 
with  a  regulating  apparatus.  The  same  objection  that  I  have 
suggested  to  Kienbock 's  method  obtains  against  Scholtz's. 
A  first  exposure  of  fifteen  minutes,  at  a  distance  of  15  to  40 

*Arch.  f.  Derm.  u.  Syph.,  1902,  lix,  p.  421. 
20 


306  TECHXiqrE  FOR  X-RAY  THERAPEUTICS. 

cm.  is  dangerous,  if  a  large  quantity  of  x-rays  is  used,  which 
is  presumably  the  case  from  Scholtz's  description. 

Oudin's  Recommendations. — Oudin  *  advised :  for  superficial 
lesions,  a  soft  tube  of  about  5  cm.  spark  equivalent ;  for  deeper 
lesions  an  extra  hard  tube  of,  say,  8  cm.  spark  equivalent;  the 
anticathode  always  placed  at  10  cm.  from  the  skin;  a  current 
of  four  amperes  and  fifteen  volts,  with  1200  interruptions  per 
minute;  first  exposure  one  minute,  second  one  and  a  half 
minutes,  third  two  minutes,  etc.,  stopping  at  first  sign  of  der- 
matitis; and  that  when  treatment  is  recommenced,  it  be  given 
three  minutes  less  than  the  last.  This  plan  of  treatment  is 
particularly  advised  in  order  that  a  common  basis  on  which 
to  judge  results  may  be  arrived  at. 

Williams'  Technique. — Williams, t  of  Boston,  whose  investi- 
gations upon  the  application  of  x-rays  in  medicine  are  among 
the  most  valuable  that  have  been  made,  uses  a  technique 
which  differs  very  considerably  from  any  other  that  has  been 
described.  The  chief  difference  in  his  technique  from  others 
is  that  he  uses  a  tube  of  very  low  vacuum,  and  he  varies  the 
quality  of  light  in  it  by  the  use  of  a  multiple  spark  gap,  which 
is  inserted  in  the  secondary  circuit.  By  an  ingenious  device 
the  number  of  spark  gaps  may  be  entirely  cut  out,  or  any 
number  of  spark  gaps  up  to  twenty-five  or  thirty  may  be  inserted 
in  the  circuit.  The  insertion  of  this  spark  gap  has  the  effect 
of  producing  x-rays  in  a  soft  tube  that  have  the  quality  of 
the  rays  produced  in  harder  tubes.  The  greater  the  number 
of  spark  gaps  inserted,  the  greater  the  penetrating  effect  of 
the  rays.  This  is  a  device  that  is  of  the  utmost  value,  I  am 
sure,  in  fluoroscopic  examinations,  but  that  it  adds  any  essential 
quality  to  the  x-rays  for  therapeutic  purposes  seems  to  me  to 
be  in  doubt. 

His  chief  reliance  in  protecting  surrounding  surfaces  from 
x-rays  is  the  enclosure  of  his  tube  in  a  box.  This  box,  which 
he  attributes  to  Rollins,  is  made  of  wrood,  painted  on  the  inside 
with  several  layers  of  lead  paint.  In  one  side  there  is  a  circular 
opening  about  5  cm.  in  diameter,  and  this  diameter  can  be 

*  Annales  de  Derm,  et  de  Syph.,  1902,  S.  iv,  t.  iii,  p.  54. 
f  The  Rontgen  Rays  in  Medicine  and  Surgery,  p.  647. 


BECK'S  TECHNIQUE.  307 

varied  by  the  use  of  a  diaphragm  of  heavy  sheet-lead.  In 
addition  to  this  lead  diaphragm,  a  diaphragm  of  plate  glass 
is  used  in  order  to  prevent  sparking  from  the  lead  plate.  By 
this  method  he  can  project  a  cone  of  x-rays  of  any  desired 
size  upon  a  diseased  surface.  He  also  at  times  protects  the 
parts  by  a  mask  of  gauze  covered  with  tinfoil  with  windows 
cut  in  it  to  correspond  to  any  area  that  he  desires  to  treat. 
He  also  covers  the  diaphragm  with  an  aluminum  sheet,  which 
is  grounded.  This  box  of  Williams  is  ingenious  and  serves  its 
purpose  well.  The  only  objection  to  it  is  that  it  is  somewhat 
cumbersome,  and  would  interfere,  I  should  think,  with  the 
application  of  x-rays  to  comparatively  inaccessible  parts  like 
the  axilla.  But  when  one  wishes  to  have  his  tube  at  some 
distance  from  the  surface,  this  box  is  one  of  the  most  ingenious 
devices  that  has  been  suggested  for  shielding  surrounding  parts 
from  x-rays.  It  is  also  serviceable  in  protecting  the  operator. 

Williams  uses  a  considerable  quantity  of  energy  in  his  tube. 
When  I  have  seen  his  work,  he  has  run  his  tube  with  the  center 
of  the  target  at  a  cherry-red  color.  He  places  the  target  at 
a  distance  of  from  10  to  15  cm.  from  the  patient  and  suggests 
that,  as  a  rule,  the  exposures  should  not  exceed  ten  minutes, 
and  at  the  beginning  be  given  not  oftener  than  twice  a  week. 
My  impression  is  that  Williams'  technique  is  highly  efficient 
in  his  hands,  but  that  it  is  unnecessarily  complicated  for  thera- 
peutic purposes  and  requires  a  high  degree  of  skill  upon  the 
part  of  the  operator.  For  his  work  Williams  uses  either  a 
very  powerful  static  machine  or  a  large  coil.  For  therapeutic 
purposes  he  prefers  a  static  machine. 

Beck's  Technique. — Carl  Beck,*  of  New  York,  does  not  give 
a  description  of  his  technique,  but  has  the  following  well- 
considered  remarks  to  make  upon  various  aspects  of  the  subject: 

"In  regard  to  the  technique  of  irradiation  for  therapeutic 
purposes,  careful  individualization  is  the  condition  sine  qua 

non At  first  it  is  best  to  expose  for  a  short  time 

and  at  long  intervals  until  the  individuality  of  the  patient 
is  well  studied.  Some  patients  react  soon,  some  after  many 
exposures,  and  some  do  not  react  at  all.  It  should  be  regarded 

*  Medical  Record,  1902,  Ixi,  p.  83. 


308  TECHNIQUE    FOR    X-RAY    THERAPEUTICS. 

as  an  iron-clad  rule  to  stop  the  exposures  as  soon  as  the  patient 
feels  a  burning  sensation  in  the  irradiated  area.  Only  after 
symptoms  of  this  kind  have  again  disappeared  entirely  the 
irradiations  may  be  repeated.  For  the  first  time  it  is  best 
to  expose  five  minutes  only.  A  week  should  elapse  then  before 
a  second  exposure  is  made.  If  after  the  third  exposure,  made 
two  weeks  later  than  the  first,  no  inflammatory  signs  have 
shown,  the  patient  does  not  seem  to  have  an  unfavorable 
idiosyncrasy,  longer  exposures  and  shorter  intervals  can  be 
attempted. 

"The  exposures  may  then  last  ten,  twenty,  or  even  forty- 
five  minutes,  and  may  be  repeated  every  other  day,  in  obstinate 
cases  even  daily.  The  risk  of  burning  the  patient  under  such 
powerful  treatment  is  not  small.  In  the  treatment  of  malignant 

disease,  however,  this  should  not  bear  great  weight 

For  the  treatment  of  most  skin  diseases,  however,  an  exposure 
of  five  to  ten  minutes,  repeated  every  third  day,  is  sufficient. 

"The  tube  is  placed  as  near  the  area  to  be  irradiated  as 
possible  (as  an  average  at  a  distance  of  about  four  inches). 

"As  a  rule,  tubes  of  low  vacuum  (soft  tubes)  should  be 
selected  for  therapeutic  purposes." 

Schiff  and  Freund's  Technique. — The  original  suggestions  of 
Schiff  and  Freund  *  as  to  technique  were  as  follows :  that  a 
coil  be  used  of  30  cm.  spark  length,  a  mechanical  interrupter 
giving  from  600  to  1000  interruptions  per  minute,  and  a  primary 
current  of  12  volts  and  1^  amperes;  that  the  length  of  exposures 
begin  at  five  minutes  and  be  increased  carefully  to  fifteen 
minutes ;  that  the  tube  be  placed  at  the  beginning  at  a  distance 
of  15  cm.  from  the  surface  and  gradually  brought  closer  to 
a  minimum  distance  of  5  cm.  They  advised  three  preliminary 
exposures  of  five  minutes  each  at  a  distance  of  15  cm.,  and 
then  a  wait  of  three  weeks  in  order  to  see  if  any  reaction  devel- 
oped. In  case  any  reaction  showed  itself  from  three  such 
exposures,  it  was  evidence  that  the  patient  had  marked  sus- 
ceptibility to  j-rays. 

Factors  Affecting  the  Quality  of  X-rays. — Schiff  and  Freund's 
original  technique  is,  I  believe,  the  most  satisfactory  attempt 

*Wien.  med.  Woclienschr.,  1898,  xlviii,  pp.  1057,  1118,  1177. 


STANDARD    LIGHT.  309 

that  has  yet  been  made  to  furnish  a  definite  plan  of  treatment. 
It  was  founded  upon  a  consideration  of  the  various  factors 
which  affect  the  intensity  of  x-rays  and  their  influence  upon 
tissues.  As  is  well  known,  these  factors  have  chiefly  to  do 
with  the  amperage  and  voltage  of  the  primary  current,  the 
capacity  of  the  coil,  the  quality  of  the  tube,  the  rapidity  of 
interruption  of  the  current,  the  distance  of  the  target  from 
the  exposed  surface,  and  the  length  of  exposures.  The  intensity 
of  the  light  in  the  tube,  all  other  factors  being  equal,  varies, 
according  to  Rontgen,  directly  with  the  strength  of  the  primary 
current.  The  character  of  the  secondary  current,  of  course, 
varies  greatly  according  to  the  winding  of  the  coil.  The  rapidity 
of  interruption  of  the  current  is  a  matter  of  minor  but  appre- 
ciable importance;  other  factors  being  the  same,  the  more 
slowly  the  current  is  interrupted  the  longer  are  the  periods 
during  which  the  current  flows,  and  the  greater  is  the  amount 
of  current  which  reaches  the  primary.  The  effect  upon  the 
tissues  varies  directly  with  the  length  of  the  exposure.  X-rays 
diverge  in  the  same  way  as  light  rays,  so  that  their  effect  upon 
any  given  surface  varies  inversely  as  the  square  of  the  distance. 
The  factor  of  all  others  among  these  which  is  hardest  to  stan- 
dardize, and  to  express  accurately,  is  the  resistance  and  the 
other  qualities  of  the  tube.  The  quality  of  the  rays  and  their 
intensity  vary  greatly  according  to  the  quality  of  the  vacuum 
in  the  tube,  and  this  is  an  unstable  factor. 

Standard  Light. — Following  the  original  suggestions  of  Schiff 
and  Freund,  I  used  as  my  standard  a  light  produced  in  a  fairly 
soft  tube  by  a  coil  of  12-inch  spark  length  with  double  winding 
of  the  primary,  with  a  primary  current  -of  twelve  volts  and 
one  and  one-half  amperes,  interrupted  a  thousand  times  per 
minute.  This  current  through  such  a  coil  produces  a  thin 
spark  about  3^  inches  in  length.  And  this  secondary  current, 
through  a  fairly  soft  new  tube,  produces  a  light  that  will  give 
clearly  the  outline  of  the  bones  of  the  hand  on  a  barium  platino- 
cyanide  screen  at  a  distance  not  exceeding  20  inches  from  the 
tube.  I  am  quite  aware  that  this  combination  of  factors  does 
not  by  any  means  give  under  all  circumstances  the  same  amount 
of  x-rays,  but  it  never  under  any  circumstances  gives  more 


310  TECHNIQUE    FOR   X-RAY   THERAPEUTICS. 

than  a  moderate  quantity  of  x-rays,  even  under  maximum 
conditions;  and  it  therefore  gives  a  light  which  for  therapeutic 
purposes  is  under  almost  all  circumstances  well  within  the 
limits  of  safety.  It  was,  I  am  sure,  of  the  utmost  value  to 
me  in  getting  my  experience  that  I  held  as  closely  as  possible 
to  this  standard  combination,  because  it  gave  me  a  fairly 
reliable  unit  of  measurement  in  doing  this  sort  of  work,  and  even 
at  the  present  time,  when  I  depart  very  widely  from  these 
original  conditions,  I  am  .sure  that  I  still  find  of  service  this 
standard  x-ray  light. 

The  mode  of  treatment  which  I  pursue  is  based  upon  the 
repeated  use  of  a  small  quantity  of  light,  rather  than  the  use 
of  more  powerful  exposures  less  frequently.  This  is,  of  course, 
done  in  the  interest  of  safety. 

Influence  of  Amperage  and  Voltage. — In  my  work  I  have  used 
coils  exclusively.  The  usual  coil  has  been  one  of  12  inches 
spark  length.  The  amperage  of  the  primary  current  is  main- 
tained between  the  extreme  limits  of  one  and  four  amperes. 
Rarely  do  I  use  a  current  of  more  than  two  and  one-half  am- 
peres. The  voltage  is  not  held  within  such  narrow  limits. 
Usually  my  voltage  ranges  between  twelve  and  thirty  volts, 
depending  upon  the  resistance  of  the  tube.  Rarely — and  very 
rarely — I  use  a  current  of  110  volts.  Given  coils  and  all  other 
conditions,  except  the  tubes,  identical,  it  does  not  make  a  very 
great  deal  of  difference  whether  110  volts  or  twenty  or  thirty 
volts  are  used.  It  is  unquestionably  true  that  safety  to  the 
patient  with  a  current  of  high  voltage  requires  considerably 
more  care  than  with  twenty  or  thirty  volts.  The  lower  voltage 
is  also  safer  for  the  apparatus.  The  amperage  is  of  more 
importance.  The  secondary  current  which  gives  a  thick  fat 
spark  and  which  is  produced  by  a  primary  current  of  high 
amperage  is  the  current  which  gives  a  large  quantity  of  x-rays, 
and  which  is  therefore  most  liable  to  cause  damage. 

Quality  of  Tubes. — With  this  rather  weak  secondary  current 
I  use  tubes  of  varying  degrees  of  hardness.  The  aim  is  to  so 
correlate  the  quality  of  the  tubes  and  the  strength  of  the  secon- 
dary current  as  to  produce  under  all  circumstances  as  nearly 
as  possible  the  same  quantity  of  x-rays.  The  determination 


DURATION   AND    DISTANCE.  311 

of  this  quantity  of  x-rays  is,  of  course,  largely  a  matter  of 
judgment  and  personal  experience,  but  a  little  practice  in 
the  use  of  one's  apparatus  under  definite  conditions  enables 
one  to  judge  with  reasonable  accuracy  of  the  intensity  of  one's 
light. 

Duration  and  Distance. — With  such  a  light,  I  begin  with 
exposures  at  15  cm.  from  the  surface  to  the  wall  of  the  tube, 
and  gradually  reduce  the  distance  so  that  by  the  end  of  two 
weeks,  if  there  is  no  evidence  of  reaction,  the  tube  is  placed 
at  a  distance  of  from  5  to  8  cm.  from  the  exposed  surface.* 
At  the  end  of  two  weeks  I  begin  to  increase  the  length  of  ex- 
posure, and  by  the  end  of  two  weeks  more  I  increase  the  time, 
if  no  reaction  appears,  up  to  fifteen  minutes.  The  maximum 
exposure  which  I  give,  except  the  rarest  cases,  is  fifteen  minutes 
at  5  cm.  from  the  wall  of  the  tube. 

Frequency  of  Exposure. — With  such  a  light  as  I  use,  exposures 
can  usually  be  given  daily  for  two  or  three  weeks  without 
the  production  of  any  marked  degree  of  dermatitis.  The  fre- 
quency of  exposures  is  varied  according  to  circumstances.  When 
it  can  be  done  and  when  it  is  desired  to  get  the  tissues  promptly 
under  the  influence  of  x-rays,  my  plan  is  to  give  exposures 
six  days  in  the  week.  With  experience  the  same  effect  may 
be  obtained  by  three  or  even  two  exposures  a  week,  but  it 
requires  a  good  deal  more  skill  in  crowding  the  exposures. 

Preliminary  Exposures  to  Determine  Susceptibility. — When, 
as  in  cases  of  acne  and  hypertrichosis,  I  wish  to  exercise  extreme 
caution,  I  give  three  preliminary  exposures  of  five  minutes 
each  with  the  tube  at  15  cm.  distance  with  a  weak  standard 
light  on  three  successive  days,  and  then  wait  three  weeks  to 
see  if  any  reaction  occurs.  This  is  after  the  suggestion  of 
Schiff  and  Freund  to  determine  idiosyncrasy.  Such  preliminary 
exposures  are,  I  believe,  an  excess  of  caution  under  most  cir- 
cumstances. 

Distance  of  Tube. — The  distance  at  which  I  place  my  tube 
is,  as  I  have  said,  from  15  to  5  cm.  from  the  surface.  When 

*Of  course,  it  is  more  accurate  to  measure  the  distance  from  the  target  to  the 
surface,  but  as  a  matter  of  convenience  I  have  always  measured  from  the  tube, 
and,  except  when  the  tube  is  very  near,  it  does  not  cause  material  error. 


312  TECHNIQUE    FOR   X-RAY   THERAPEUTICS. 

it  is  desired  to  produce  a  decided  effect,  the  tube  is  usually 
maintained  at  5  to  8  cm.  There  is  an  objection  to  the  use 
of  the  tube  very  close  in  case  it  is  desired  to  influence  a  large 
surface,  for  the  reason  that  under  such  circumstances  the 
effect  is  relatively  so  much  greater  at  the  point  directly  beneath 
the  target.  For  this  reason  if  a  large  surface  is  to  be  influ- 
enced,— as,  for  example,  the  entire  back  in  treating  an  acne,— 
it  is  necessary  to  place  the  tube  at  a  greater  distance,  say  15 
to  30  cm. 

If  exposures  are  to  be  given  daily  with  the  tube  at  a  distance 
of  5  cm.  and  ten  to  fifteen  minutes'  duration,  one  must  be 
careful  to  keep  a  weak  light.  With  a  light  such  as  I  have 
attempted  to  describe,  the  exposure  can  be  continued  daily, 
as  I  have  done  in  many  cases,  without  ever  producing  a  serious 
burn.  I  have  made  many  thousand  exposures  of  the  above 
character,  in  many  instances  have  produced  acute  dermatitis 
intentionally,  but  I  have  never  in  any  case  had  a  burn  that 
caused  destruction  of  the  connective  tissue.  I  feel  able  to  push 
these  treatments,  therefore,  with  considerable  assurance — a 
point  of  importance  when  a  prompt  effect  is  desired. 

Record  of  Exposures. — It  has  been  my  practice  from  the 
start  to  keep  as  accurate  a  record  as  possible  of  all  the  factors 
of  the  exposure.  A  copy  of  the  record  sheet  which  I  have 
used  is  shown  in  miniature  in  figure  97.  The  following  data  are 
recorded  for  each  exposure:  the  number  and  date  of  the  ex- 
posure, the  voltage  and  amperage  of  the  primary  current, 
the  distance  of  the  tube  from  the  surface,  the  length  of  ex- 
posure, the  number  of  interruptions  per  minute,  the  area 
exposed,  the  quality  of  the  tube,  and  the  intensity  of  the  light. 
For  convenience  I  have  classified  the  tubes  into  hard,  medium, 
and  soft,  and  the  quality  of  light  as  weak,  medium,  strong, 
and  very  strong.  With  a  little  attention  to  system,  the  record- 
ing of  all  these  data  gives  very  little  trouble,  and  the  possession 
of  such  data  in  many  cases  I  have  found  of  the  utmost  value 
in  formulating  methods  of  procedure  in  any  given  case. 

Necessary  Apparatus. — To  carry  out  the  technique  that  I 
use  the  apparatus  required  consists  of  a  coil,  motor  generator 
or  storage  battery,  switchboard  with  volt  meter  and  ammeter 


NECESSARY   APPARATUS. 


313 


and  necessary  switches  and  rheostats,  mechanical  interrupter, 
tube-holder,  tubes,  and  lead  masks.  The  various  parts  of 
this  apparatus  will  be  taken  up  in  considering  apparatus  in 
general.  An  apparatus  such  as  I  use  is  shown  in  figure  98. 

It  will  be  evident  from  the  foregoing  description  of  the  tech- 
niques of  different  workers  that  any  technique  is  largely  a 
matter  of  personal  experience.  Different  workers  arrive  at  the 
same  end  by  very  different  methods.  It  is  for  this  reason  that 
I  have  thought  it  worth  while  to  describe  in  some  detail  the 


Name. 


No. 

Date. 

Volts. 

Amp. 

Dist. 

Time. 

Inter. 

Area. 

Fig.  97. 

methods  of  several  of  the  best-known  workers  in  this  field, 
and  for  the  same  reason  I  have  ventured  to  impose  on  the 
reader's  patience  a  somewhat  detailed  description  of  my  own. 
Whatever  plan  of  treatment  the  worker  adopts  it  is  well 
in  my  opinion  to  stick  to  one  technique  as  closely  as  possible, 
in  order  that  he  may  accumulate  an  experience  under  as  definite 
conditions  as  possible.  It  is  only  by  such  a  systematic  tech- 
nique that  he  can  profit  by  his  past  experience. 


314  TECHNIQUE    FOR   X-RAY   THERAPEUTICS. 

How  Far  Should  X-ray  Effects  be  Carried? — In  many  condi- 
tions, as  acne,  eczema,  and  other  inflammatory  conditions  of 
the  skin,  it  is  possible  to  get  rid  of  the  disease  without  at  any 
time  producing  apparent  x-ray  effects  upon  the  skin,  and  in 
such  cases  it  is  not  necessary  to  carry  the  treatment  to  the 
point  of  producing  any  reaction  in  the  tissues.  In  other  condi- 
tions it  may  be  necessary  to  push  the  x-rays  much  further, 
and  under  such  circumstances  the  question  constantly  arises, 
How  far  shall  the  x-ray  effects  be  pushed?  The  rule  is  fre- 
quently laid  down  that  exposures  should  be  stopped  imme- 
diately upon  the  first  appearance  of  reaction  in  the  skin.  That 
is  a  rule  that  I  usually  follow  in  the  first  treatment  of  any 
case,  and  never  transgress  in  the  treatment  of  minor  troubles 
like  acne. 

As  a  rule,  upon  the  first  appearance  of  any  effect  upon  the 
skin  the  treatment  is  stopped, — unless  the  situation  is  grave,— 
and  I  then  wait  for  the  reaction  to  subside.  When  this  sub- 
sides, the  treatment  is  again  begun. 

If  the  patient  has  shown  no  marked  susceptibility  to  the 
effect  of  x-rays,  and  there  is  reason  for  pushing  the  treatment, 
the  second  time  I  do  not  hesitate  to  continue  the  treatment 
in  spite  of  moderate  dermatitis.  Under  certain  conditions  I 
push  the  treatment  up  to  the  development  of  an  acute  weeping 
dermatitis,  and  in  very  rare  instances  I  have  continued  treat- 
ment for  a  considerable  time  over  such  a  dermatitis.  Of  course, 
that  should  not  be  done  unless  the  situation  is  sufficiently 
grave  to  warrant  the  risk,  and  then  should  be  done  with  as 
much  caution  as  possible.  It  is  by  no  means  always  necessary 
to  carry  the  exposure  to  the  point  of  producing  dermatitis 
in  the  healthy  skin  in  order  to  destroy  pathological  tissues. 
For  example,  in  Case  76,  page  472,  of  extensive  recurrent  car- 
cinoma of  the  chest-wall,  all  of  the  carcinomatous  tissue  dis- 
appeared, and  was  replaced  by  healthy  scar  tissue  without 
even  an  erythema  ever  being  produced.  There  was  slight 
pigmentation,  but  nothing  more.  On  the  other  hand,  in  a 
similar  case,  Case  75,  page  471,  it  was  found  necessary  to  carry 
the  reaction  to  the  point  of  producing  an  acute  weeping  derma- 
titis repeatedly  before  the  carcinomatous  nodules  disappeared. 


Fig.  98. — An  x-ray  outfit  for  therapeutic  use. 
315 


COILS   VS.    STATIC   MACHINES.  317 

Tissues  vary  a  great  deal  in  these  respects,  and  each  case  has 
to  be  treated  according  to  its  individual  peculiarities.  I  wish 
to  emphasize,  however,  the  fact  that  in  carcinoma  and  other 
malignant  diseases  it  is  by  no  means  always  necessary  to  produce 
an  x-ray  burn,  even  of  the  first  degree,  in  order  to  get  rid  of 
the  diseased  tissue.  Johnson  and  Merrill,*  in  considering  this 
point,  suggest  that  it  is  necessary  to  produce  an  x-ray  burn, 
according  to  the  reports  in  the  literature,  in  order  to  get  rid 
of  an  epithelioma,  and  therefore  they  see  no  reason  why  the 
operator  should  not  proceed  to  do  this  as  quickly  as  possible. 
I  am  sure  from  my  experience  that  it  is  not  always  necessary 
to  produce  an  x-ray  burn  in  order  to  get  rid  of  malignant  growths. 
In  a  general  way,  of  course,  much  more  care  must  be  exer- 
cised to  avoid  burns  in  conditions  that  are  not  grave  than 
in  serious  malignant  diseases.  The  greatest  care  is  to  be  exer- 
cised in  treating  simple  skin  diseases,  which  at  their  worst 
are  perhaps  less  serious  than  an  x-ray  burn.  In  the  treatment 
of  malignant  diseases  much  less  care  may  be  exercised  as  regards 
the  factors  of  safety,  and  under  some  circumstances  they  may 
be  disregarded,  and  all  energies  bent  to  the  production  of 
x-ray  effect  upon  the  tissues  as  quickly  as  possible,  regardless 
of  the  risk  of  burn. 

There  are  certain  questions  pertaining  to  technique  which 
have  only  been  considered  incidentally  in  the  foregoing  and 
which  need  a  more  general  consideration. 

Apparatus. — Most  of  those  who  have  used  x-rays  for  thera- 
peutic purposes  have  used  induction  coils  as  their  source  of 
energy.  Some  have  used  static  machines,  and  a  very  few 
have  used  the  so-called  Tesla  high  frequency  apparatus. 

Coils  vs.  Static  Machines. — I  prefer  coils  to  static  machines, 
for  the  reason  that  the  amount  of  energy  to  be  used  can,  in 
my  opinion,  be  gauged  more  accurately  with  the  coil,  and 
can  also  be  more  accurately  regulated.  Williams,  on  the  other 
hand,  prefers  the  static  machine.  It  is  doubtless  a  good  deal 
a  matter  of  personal  experience.  There  is  no  reason  to  believe 
that  the  x-rays  themselves  produced  by  a  static  machine  differ 

*  Phila.  Med.  Jour.,  1900,  vi,  p.  1138. 


318  TECHNIQUE    FOR   X-RAY   THERAPEUTICS. 

in  any  way  from  those  produced  by  a  coil.  It  is  only  a  question, 
therefore,  of  convenience  and  accuracy  in  the  management  of 
the  agent.  In  the  hands  of  an  expert  worker  the  static  machine 
may  doubtless  be  used  as  a  source  of  x-rays  with  as  much 
safety  as  the  most  carefully  regulated  coil.  A  static  machine 
does,  however,  require  more  skill  to  keep  it  well  within  the 
bounds  of  safety.  There  is,  in  my  opinion,  not  the  slightest 
vestige  of  reason  for  the  claim  that  x-rays  produced  by  a  static 
machine  are  less  liable  to  cause  burns  than  those  produced 
by  coils.  Upon  this  point  Codman  *  makes  the  following 
very  conservative  statement:  "Many  assertions  have  been  made 
that  the  static  machine  is  less  liable  to  cause  injury  than  other 
forms  of  apparatus  because  of  the  lower  amperage  of  its  output. 
This  statement  is  not  entirely  borne  out  by  the  present  analysis. 
In  the  cases  in  which  the  kind  of  apparatus  is  recorded  eleven 
were  caused  by  static  machines;  of  these,  three  were  severe. 
Eleven  were  caused  by  Tesla  coils;  of  these,  five  were  severe. 
Forty-two  were  caused  by  forms  of  induction  coil;  of  these, 
eighteen  were  severe.  On  the  other  hand,  coils  have  been  far 
more  commonly  used  than  static  machines  or  the  Tesla  apparatus 
— probably  more  than  three  times  as  much."  As  bad  burns 
as  there  are  recorded  in  the  literature  have  been  produced 
with  static  machines,  as  witness  the  case  reported  by  Cassidy.t 
This  is,  of  course,  no  argument  against  the  use  of  static  machines 
for  therapeutic  purposes,  for  unquestionably  x-rays  which  would 
not  produce  burns  (if  such  existed)  would  be  of  no  service 
in  the  therapeutic  use  of  the  agent.  The  quality  in  x-rays 
that  produces  burns  is  the  same  quality  that  is  utilized  in  the 
therapeutic  application  of  the  agent.  The  Tesla  high  frequency 
apparatus  is,  in  my  opinion,  less  to  be  recommended  for  the 
production  of  x-rays  for  therapeutic  purposes  than  either  of 
the  other  two  forms.  It  produces  a  large  quantity  of  x-rays,  and 
its  use  therefore  requires  more  care  than  either  of  the  others. 
It  has  been  used,  however,  in  the  successful  application  of  x-rays 
to  therapeutic  purposes.  It  has  a  minor  objection,  in  that  it 
very  rapidly  blackens  the  tubes  and  causes  their  deterioration. 
Coils. — For  most  of  my  work  I  have  used  coils  of  12-inch 

*Phila.  Med.  Jour.,  1902,  ix,  p.  438.         t  Medical  Record,  1900,  Ivii,  p.  180. 


SOURCES   OF   ENERGY.  319 

spark  length  with  double  windings  of  the  primary,  so  arranged 
that  they  can  be  connected  either  parallel  or  in  series.  A 
number  of  writers  have  recommended  much  larger  coils,  but 
without  reasons  that  to  my  mind  are  conclusive.  A  coil  that 
will  produce  a  good  spark  of  12  inches  can  furnish  more  energy 
than  we  can  utilize  or  than  would  be  safe  for  therapeutic  pur- 
poses if  we  had  a  tube  that  would  take  it.  In  my  work  I  rarely 
use  a  current  of  sufficient  strength  to  produce  a  12-inch  spark,  so 
that  even  smaller  coils  may  be  used.  Indeed  as  a  portable  appa- 
ratus I  have  constantly  used  with  satisfaction  coils  of  6  or  7  inches 
spark  length  with  vibrator  interrupter  and  storage  batteries. 

Sources  of  Energy. — On  account  of  the  convenience  of  its 
use  the  110- volt  direct  current  taken  directly  from  lighting 
circuits  is  often  recommended,  particularly  by  the  manufac- 
turers of  electrical  instruments.  It  can  unquestionably  be 
used,  but  it  cannot  be  used,  I  am  convinced,  with  as  much 
safety  as  a  current  of  lower  potential.  For  that  reason,  although 
I  have  always  had  the  110-volt  continuous  current  at  my 
disposal,  I  have  for  most  of  my  work  converted  it,  either 
by  the  use  of  a  storage  battery  or  a  motor  generator,  to  a  current 
of  lower  voltage.  It  is  easy  to  have  the  wiring  of  one's  switch- 
board so  arranged  that  the  110-volt  current  can  be  made  avail- 
able, and  at  times  it  is  desirable  to  use  it;  but  for  the  sake 
of  uniformity  in  technique,  if  not  for  safety,  I  very  rarely 
avail  myself  of  it.  For  converting  the  110-volt  current  to  a 
lower  voltage  either  a  storage  battery  or  a  motor  generator 
is  satisfactory.  My  storage  batteries  are  arranged  so  that  any 
voltage  from  12  to  25  volts  can  be  obtained,  and  so  that  they 
can  be  stored  by  simply  throwing  a  switch.  I  have  found 
storage  batteries  so  arranged  entirely  satisfactory  for  my  work. 
More  frequently  than  a  storage  battery  I  use  a  motor  generator 
so  wound  that  any  voltage  between  10  and  40  volts  can  be 
obtained.  A  one-fourth  horse-power  generator  will  furnish 
ample  energy.  For  continuous  use  a  motor  generator  is  perhaps 
more  satisfactory  than  a  storage  battery. 

Meters. — For  the  sake  of  accuracy  I  have  constantly  used 
meters  on  my  primary  current:  a  volt  meter  registering  from 
1  to  120  volts  and  an  ammeter  registering  from  \  to  10  amperes. 


320  TECHNIQUE    FOR   X-RAY   THERAPEUTICS. 

In  my  opinion  they  are  highly  desirable,  though  not  absolutely 
necessary,  additions  to  the  apparatus,  since  they  furnish  a 
factor  of  stability  and  safety  in  the  technique.  A  tachometer 
to  register  the  number  of  interruptions  in  the  current  is  a 
desirable  but  not  necessary  part  of  the  apparatus. 

Interrupters. — For  small  coils  the  ordinary  vibrator  inter- 
rupter gives  satisfactory  results,  but  for  coils  above  7  or  8 
inches  spark  length  it  is  usually  not  satisfactory.  There 
are,  however,  being  put  on  the  market  at  present  some  coils 
of  12  and  15  inches  spark  length,  equipped  with  vibrator  inter- 
rupters, that  give  good  results.  There  are  various  forms  of 
mechanical  interrupters  in  use.  The  dip  interrupter,  in  which 
the  current  is  made  by  the  rapid  dipping  of  a  platinum  tip 
in  mercury  under  kerosene  or  alcohol,  and  the  turbine  inter- 
rupter, in  which  the  current  is  made  by  a  rapidly  revolving 
jet  of  mercury  impinging  upon  the  segments  of  a  metal  collar, 
are  the  two  principal  types.  Either  answers  the  purpose 
satisfactorily.  In  its  present  perfection  the  turbine  interrupter 
is  perhaps  the  best  type.  The  dip  interrupter,  however,  has 
one  very  material  advantage  over  the  turbine  interrupter  for 
therapeutic  purposes,  and  that  is  the  amount  of  amperage 
of  the  circuit  can  be  conveniently  regulated  without  changing 
the  voltage  by  varying  the  depth  to  which  the  needle  of  the 
interrupter  dips  into  the  mercury.  The  electrolytic  or  Wehnelt 
interrupter  is  not  quite  so  satisfactory  for  therapeutic  purposes, 
because  it  requires  a  high  initial  voltage,  and  in  a  coil  that 
is  ordinarily  wound  it  produces  a  heavy  spark.  To  get  such 
a  spark  as  I  use  with  a  Wehnelt  interrupter  requires  a  special 
winding  of  the  primary  in  three  or  four  la}rers,  and  this  winding 
is  not  suitable  for  any  other  interrupter.* 

Tube-holders. — A  tube-holder  made  of  iron  tubing  which  I 
have  found  very  convenient  is  shown  in  figure  99.  A  similar 
tube-holder,  which  has  the  advantage  of  being  made  of  wood, 
is  shown  in  figure  100.  I  have  found  these  holders  convenient 
for  therapeutic  work  because  the  arm  holding  the  tube  is  long 
and  the  tube  can  be  readily  adjusted  in  any  position. 

*  Walter:  Fortschr.  a.  d.  Geb.  d.  Rontgenstrahlen,  1900,  iv,  p.  46;  1901, 
v,  13. 


TUBES. 


321 


Tubes. — As  is  well  known,  tubes  are  described  as  hard  or 
high,  or  soft  or  low,  after  the  suggestion  of  Rontgen,  according 
to  the  character  of  the  vacuum  and  the  resistance  which  they 
offer  to  the  electrical  current.  A  tube  is  spoken  of  as  soft 
when  it  is  of  low  vacuum  and  of  correspondingly  low  resistance ; 
as  hard  when  the  vacuum  is  relatively  high  and  the  resistance 
correspondingly  increased.  The  quality  and  quantity  of  the 
x-rays  vary  according  to  the  degree  of  vacuum  of  the  tube. 


Fig.  99. 


Fig.  100. 


The  rays  from  a  soft  tube  are  of  relatively  low  penetration, 
and  this  penetrating  power  increases  directly  with  the  degree 
of  hardness  of  the  tube.  The  quantity  of  x-rays  also  varies 
with  the  hardness  of  the  tube.  A  soft  tube  will,  under  given 
conditions  of  current,  produce  a  larger  quantity  of  x-rays  than 
a  hard  tube.  The  quality  and  quantity  of  the  rays  also  vary 
considerably  with  the  age  of  the  tube.  A  new  tube  under 
given  conditions  of  current  will  produce  a  larger  quantity  of 

21 


322  TECHNIQUE    FOR   X-RAY    THERAPEUTICS. 

z-rays  than  can  be  produced  in  the  same  tube  under  the  same 
conditions  after  it  has  been  used  for  a  long  time,  regardless 
of  its  vacuum.  A  tube,  moreover,  tends  to  become  harder 
from  use,  so  that  for  this  reason,  also,  to  produce  a  given  quan- 
tity of  light  a  larger  quantity  of  energy  will  be  required  in 
the  old  tube  than  in  the  new  one.  It  is  a  fact  of  practical 
interest  that  old  tubes  may  be  improved  by  giving  them  rest 
from  use.  I  am  using  now  the  first  tube  I  ever  used;  it  became 
so  high  that  no  x-rays  could  be  gotten  from  it,  but  after  a 
rest  of  several  months  it  was  restored  to  moderate  hardness. 

No  satisfactory  standard  for  classifying  or  describing  tubes 
has  yet  been  found.  The  usual  plan  of  expressing  the  hardness 
of  tubes  is  by  describing  them  in  equivalent  spark  length. 
A  given  tube  has  an  equivalent  resistance  of  so  many  centi- 
meters spark  length;  that  is,  the  resistance  which  the  tube 
offers  to  the  passage  of  the  current  is  the  same  as  that  offered 
by  a  certain  spark  gap  in  the  air,  so  that  if  this  spark  gap  is 
made  less  the  current  will  pass  across  the  gap  rather  than 
through  the  tube,  or  if  greater  will  pass  through  the  tube  rather 
than  across  the  gap.  This,  however,  expresses  only  the  re- 
sistance of  the  tube  and  furnishes  no  accurate  statement  of 
the  light  produced  by  such  a  tube. 

The  usual  and  perhaps  the  most  practical  way  of  describing 
the  light  from  any  tube  is  by  using  the  shadow  cast  by  the 
hand  as  a  standard.  The  difference  in  the  shadows  of  the 
hand  produced  by  x-rays  of  different  degrees  of  penetra- 
tion is  very  well  shown  diagramatically  in  the  accompanying 
illustrations  taken  from  Kienbock  *  (Fig.  101). 

In  the  treatment  of  pathological  conditions  tubes  must  be 
selected  with  a  view  to  the  depth  of  tissue  which  it  is  desired 
to  affect.  It  is  generally  accepted  that  soft  tubes  produce  a 
greater  effect  upon  the  superficial  tissues  than  hard  tubes 
(Scholtz,f  Taylor,J  Kienbock, §  and  Sharpe|l).  This  is  un- 
doubtedly for  the  reason  that  only  those  rays  which  are  absorbed 

*Wien.  klin.  Woch.,  1900,  xiii,  p.  1153. 

t  Arch.  f.  Derm.  u.  Syph.,  1902,  lix,  p.  241.  }  Lancet,  1902,  i,  p.  1395. 

I  Wien.  klin.  Woch.,  1900,  xiii,  pp.  1153,  116(i. 

||  Archives  of  the  Rontgen  Rays,  1901,  v,  p.  83. 


TUBES. 


323 


by  the  tissues  produce  any  effect  upon  them,  and  the  rays 
from  a  soft  tube  are  absorbed  by  the  most  superficial  tissues, 
while  those  from  hard  tubes  pass  through  the  superficial  tissues 


Fig.  101. — 7,  Tube  which  is  so  hard  and  of  such  high  resistance  that  the 
current  cannot  be  forced  through  it,  but  passes  around  it  through  the  air.  Gives 
no  Rontgen  rays.  //,  Hard  tube  of  high  resistance  giving  Rontgen  rays  of  high 
penetrating  quality.  The  soft  parts  and  the  bones  are  about  equally  well  pene- 
trated by  the  rays,  and  very  little  light  is  absorbed.  The  shadow  of  the  hand 
given  by  such  a  tube  is  shown  in  VI.  Ill,  Medium  soft  tube.  Almost  the  en- 
tire electrical  current  passes  through  the  tube  and  is  transformed  into  Rontgen 
rays.  Gives  an  intense  radiance  of  moderate  penetration.  Shadow  of  the  hand 
from  such  a  tube  is  shown  in  VII.  IV,  Very  soft  tube.  Gives  intense  ar-rays 
with  a  current  of  low  power.  Its  light  has  only  a  slight  penetrating  power.  In 
the  shadow  picture  (  VIII )  both  the  soft  tissues  and  the  bones  are  dark.  V,  Tube 
which  is  so  soft  that  no  ar-rays  are  produced. 


324  TECHNIQUE   FOR   X-RAY   THERAPEUTICS. 

with  a  minimum  absorption.  There  is  accordingly  a  well- 
defined  consensus  of  opinion  that  in  the  treatment  of  superficial 
conditions  like  skin  diseases  soft  tubes  are  the  most  suitable, 
while  for  deep-seated  conditions  hard  tubes  of  greater  pene- 
tration must  be  used.  I  have  no  doubt  of  the  accuracy  of 
this  position.  Deep-seated  conditions,  if  they  are  to  be  affected 
at  all,  can  be  affected  only  by  relatively  hard  tubes;  while 
superficial  conditions  are  most  readily  affected  by  soft  tubes. 
From  all,  however,  but  the  tubes  of  highest  vacuum  x  -rays 
can  be  produced  which  will  show  a  perceptible  effect  on  the 
most  superficial  tissues;  for  no  matter  how  high  a  tube  may 
be,  some  of  the  rays  are  absorbed  by  the  first  tissues  they 
strike.  For  the  treatment  of  deep-seated  processes  I  have  at 


I 


Fig.  102. — Tube  with  regenerating  attachment. 

times  used  with  apparent  success  very  old  and  very  hard  tubes 
whose  rays  were  of  such  penetrating  power  that  they  produced 
almost  no  effect  upon  a  fluorescent  screen.  Very  few  of  the 
rays  from  such  a  tube  are  absorbed  by  the  skin,  so  that  the 
treatment  of  deep-seated  affections  can  be  carried  out  much 
more  vigorously  with  such  tubes  than  would  otherwise  be 
possible. 

As  to  the  variety  of  tubes  which  should  be  used,  I  have 
not  found  any  one  make  that  shows  distinct  superiority  over 
all  others.  The  style  of  tube  which  I  usually  use  is  the  ordinary 
spherical  tube  (Fig.  102).  These  tubes  are  furnished  either 
without  regulating  device  or  with  a  capillary  tube  of  palladium 
alloy,  as  suggested  by  Villard,*  protruding  through  the  tube 

*Londe:  Annales  de  la  Conservatoire  des  Arts  et  dea  Metiers,  1899,  3e  Serie, 
i,  p.  153. 


PROTECTIVES.  325 

wall,  by  heating  which  the  vacuum  in  the  tube  can  be  lowered. 
The  tubes  with  this  regulating  device  are  worth  the  small 
difference  in  price  between  them  and  the  non-regulating  tubes. 
The  tubes  with  the  so-called  self-regulating  device  I  have  not 
found  to  possess  marked  superiority  for  therapeutic  work. 
They  have  a  little  longer  life,  but  the  difference  in  this  respect 
has  not  been  sufficient  to  compensate  for  their  greater  cost. 
If  one  has  a  single  x-ray  tube,  it  is  perhaps  better  to  have 
one  of  these  self-regulating  tubes,  but  it  has  seemed  to  me 
a  better  plan  to  have  several  tubes  of  different  ages  and  different 
vacua,  from  which  one  may  select  a  tube  to  suit  any  particular 
case.  Another  advantage  in  having  several  tubes  is  that  the 
tubes  may  be  rested  for  a  while,  for  those  that  are  put  out 
of  use  for  several  days  or  weeks  often  regain  some  of  their 
lost  quality.  I  prefer  tubes  of  medium  size,  with  a  bulb  about 
six  inches  in  diameter.  Such  a  tube  is  large  enough  to  have 
a  relatively  stable  vacuum  and  not  so  large  as  to  be  incon- 
venient for  use.  At  times  smaller  tubes  with  a  diameter  of 
bulb  of  4^  inches  are  convenient  for  treating  the  perineum, 
axilla,  and  other  comparatively  inaccessible  parts.  For  use 
in  cavities — as  the  vagina,  rectum,  mouth — Caldwell's  tube  is 
of  the  utmost  value. 

Protectives. — In  all  methods  of  using  x-rays  for  therapeutic 
purposes  provisions  are  made  for  protecting  the  surfaces  sur- 
rounding the  part  to  be  treated.  There  are  two  ways  of  doing 
this:  one  is  to  surround  the  tube  with  an  opaque  covering  so 
that  the  rays  have  exit  only  at  one  point ;  the  other  is  to  protect 
by  some  opaque  covering  the  surfaces  of  the  body  which  are 
within  the  influence  of  the  rays.  The  first  method  is  usually 
carried  out  by  placing  the  tube  in  a  box.  An  example  of 
these  boxes  is  Williams'  box  (Fig.  103),  to  which  reference  has 
already  been  made.  The  advantages  of  and  objections  to  this 
plan  have  been  briefly  referred  to  in  considering  Williams' 
technique  on  page  306.  The  second  method  consists  in  using 
shields  to  cover  the  surface  adjacent  to  the  tube,  with  openings 
cut  in  them  to  correspond  to  the  area  which  it  is  desired  to 
expose.  The  first  material  suggested  for  these  shields  was 
lead,  and  lead  in  some  form  is  the  material  still  generally  used. 


326 


TECHNIQUE    FOR    X-RAY    THERAPEUTICS. 


Schiff  and  Freund  *  suggested  sheet-lead,  -^  of  an  inch  thick, 
to  be  covered  with  blotting-paper.  Kienbock  f  uses  lead 
plates  which  he  covers  with  flannel.  Williams  uses  for  the 
face  "a  mask  made  of  gauze  and  pressed  into  the  shape  of 
the  face,  such  as  may  be  purchased  at  theatrical  supply  houses," 
and  he  covers  this  with  tinfoil.  Others  have  suggested  the  use 
of  several  layers  of  lead-foil  such  as  is  used  for  lining  tea  boxes. 
I  use  in  my  work  sheet-lead  ^  or  •£%  of  an  inch  thick.  Re- 
cently I  have  used  sheets  made  from  an  alloy  of  95  per  cent, 
lead  and  5  per  cent.  tin.  This  has  the  advantage  of  being 
bright  and  clean  and  not  rubbing  off  in  handling.  Rontgen 
states  that  sheet-lead  y1^-  of  an  inch  thick  practically  excludes 


Fig.  103.— Williams'  tube-box. 

all  x-rays.  I  have  found  on  trial  that  a  rapid  photographic 
plate  covered  with  lead  -^  of  an  iruch  thick  shows  almost  no 
trace  of  x-rays  after  fifteen  minutes'  exposure  to  a  strongly 
lighted  hard  tube.  Fifteen  minutes'  exposure  to  a  similar  light 
of  a  photographic  plate  covered  by  j\  inch  lead  shows  apprecia- 
ble but  very  slight  effect.  The  ^  inch  lead  therefore  probably 
furnishes  perfect  protection.  However,  I  have  found  that  lead 
3*2-  of  an  inch  thick  is  not  too  thick  to  be  conveniently  handled, 
and  it  is,  I  believe,  best  for  these  masks.  Lead  of  this 
thickness  can  be  obtained  in  any  width  from  any  plumbers' 

*AVien.  med.  Woch.,  1898,  xlviii,  pp.  1057,  1118,  1177. 
f  Interstate  Med.  Jour.,  1902,  ix,  pp.  1,  GO. 


MASKS   FOR   SPECIAL   PARTS   OF   THE    BODY.  327 

supply  house.  My  practice  from  the  start  has  been  to  cover 
the  masks  on  both  sides  with  ordinary  wrapping-paper.  This 
makes  them  clean  to  handle,  furnishes  satisfactory  insulation, 
and  has  the  convenience  of  being  easily  washed  off  and  replaced. 
It  is  simpler  than  the  other  coverings  suggested  and  can  be 
more  readily  renewed.  These  lead  sheets  can  be  made  of  any 
size,  with  apertures  in  them  of  any  desired  shape,  and  very 
little  ingenuity  is  required  to  adapt  them  to  any  of  the  sur- 
faces of  the  body.  For  most  work  about  the  face  these  masks 
can  be  very  readily  adapted  without  especial  shaping,  but  when 
it  is  desired  to  make  a  mask  of  the  shape  of  the  face  I  have 
found  it  exceedingly  convenient  to  possess  a  model  of  the  head 
and  neck  made  in  wood.  On  this  mould  it  is  easy  after  a  little 
practice  to  hammer  these  lead  sheets  into  perfect  masks  of 
the  face.  Holes  of  any  shape  can  be  cut  in  them  and  the 
masks  then  covered  with  paper.  For  exposing  special  parts 
masks  of  special  design  are  required,  but  with  a  little  pa- 
tience I  have  never  found  it  difficult  to  adapt  a  mask  to  any 
part  of  the  body. 

Masks  for  Special  Parts  of  the  Body. — In  making  exposures 
in  the  mouth  and  pharynx  I  have  used  a  lead  mask  of  sufficient 
size  to  cover  the  face ;  to  this  is  soldered  at  right  angles  a  short 
piece  of  block-tin  pipe  such  as  plumbers  use,  and  a  hole  is 
cut  through  the  mask  to  correspond  with  the  hole  in  the  pipe. 
This  pipe  can  be  moulded  or  cut  to  the  shape  desired.  In 
this  way  a  speculum  can  be  improvised  which  I  have  found 
quite  useful.  The  patients  have  not  objected  to  it.  For  making 
vaginal  exposures  I  have  used  the  ordinary  Ferguson  short 
glass  specula.  The  patient  is  placed  on  an  ordinary  gyneco- 
logical table  on  the  back  with  the  knees  drawn  up  as  for  vaginal 
examination.  The  thighs  are  protected  by  lead  masks  which 
reach  from  below  the  knees  to  the  inguinal  folds ;  another  mask 
is  made  wide  enough  entirely  to  protect  the  perineum,  with  a 
slit  in  it  corresponding  in  width  to  the  speculum.  This  is 
placed  around  the  speculum  in  such  a  way  as  to  protect  the 
perineum.  The  speculum  must  be  retained  in  position  by  an 
assistant's  hand,  and  the  additional  protection  needed  in  order 
to  cover  all  exposed  parts  is  furnished  by  a  lead  mask  which 


328  TECHNIQUE    FOR    X-RAY    THERAPEUTICS. 

the  assistant  places  around  her  hand.  This  plan  of  protecting 
the  perineum,  while  apparently  cumbersome,  has  proved  satis- 
factory and  not  difficult  to  carry  out. 

For  making  exposures  in  the  mouth  *or  in  the  vagina  or  in 
the  rectum  CaldwelPs  tubes  (Figs.  21-24)  furnish  far  and  away 
the  best  method.  Indeed,  his  tubes  for  treating  these  cavities 
is,  in  my  opinion,  the  greatest  single  addition  that  has  been 
made  to  the  technique  of  the  therapeutic  application  of  x-rays. 

The  most  difficult  skin  surface  to  reach  is  that  around  the 
eyes.  Lesions  at  the  canthi  can  easily  be  treated  because  of 
their  distance  from  the  cornea,  but  in  treating  lesions  of  the 
lower  lid  and  of  the  upper  lid  it  is  more  difficult  to  protect 
the  eyes.  It  is  difficult  to  protect  the  conjunctiva  in  expos- 
ing the  upper  lids.  In  such  cases  one  has  to  rely  largely 
upon  giving  the  exposures  very  cautiously.  Fortunately  the 
commonest  lesions  which  we  are  called  upon  to  treat  about 
the  eye,  epitheliomata,  rarely  occur  primarily  on  the  upper 
lid.  Lesions  on  the  lower  lid  I  have  been  able  to  treat 
very  easily  by  shaping  the  masks  to  correspond  with  the 
curve  of  the  eyeball  and  carefully  cutting  slits  to  corre- 
spond to  the  area  on  the  lower  lid  to  be  exposed.  Then, 
when  making  the  exposure,  I  have  the  lower  lid  pulled 
down  in  order  to  get  it  as  far  away  from  the  bulb  as  possible. 
This  can  be  done  convenient!}"  by  taking  a  strip  of  adhesive 
plaster  and  fastening  it  below  the  border  of  the  lid  where  the 
tissues  are  lax,  and  having  the  patient  exercise  continuous 
slight  traction  downward  during  the  exposure.  By  a  little  care 
and  ingenuity  it  is  not  difficult  to  treat  lesions  about  the  eye. 
Sometimes,  however,  in  spite  of  the  utmost  caution  some  con- 
junctivitis will  be  caused,  and  if  the  conjunctiva  or  the  cornea 
has  to  be  exposed  conjunctivitis  may  be  severe.  All  of  the 
conjunctivitides  that  I  have  seen  under  the  influence  of  x-ray 
exposures  have  yielded  to  instillation  of  protargol  solution  and 
boric  acid  solution,  after  the  manner  of  treating  ordinary 
conjunctivitis. 

A  good  deal  of  ingenuity  has  been  wasted  in  trying  to  devise 
masks  to  supersede  lead  or  other  metals  opaque  to  x-rays. 
Among  others  hard-rubber,  papier-mache,  and  celluloid  masks 


ALUMINUM    SCREENS.  329 

have  been  suggested.  None  of  these  is  opaque  to  x-rays, 
and  none  furnishes  adequate  protection  against  the  effect 
of  x-rays  on  tissues.  ,  If  for  any  reason  it  is  impossible  to 
use  lead,  some  slight5  protection  may  be  obtained  from  the 
use  of  the  oxid  of  zinc  adhesive  plaster.  It  is  also  possible 
to  make  a  paste  of  an  indifferent  ointment  and  some  powder 
opaque  to  x-rays  that  will  give  protection.  If  bismuth  sub- 
nitrate,  which  is  opaque  to  x-rays,  is  rubbed  in  sufficient  quan- 
tities with  vaselin,  or  any  other  indifferent  ointment,  a  paste 
may  be  made  which  furnishes  strong  obstruction  to  x-rays.  A 
layer  £  of  an  inch  thick  of  a  paste  made  of  two  parts  by 
weight  of  bismuth  subnitrate  and  one  of  diachylon  ointment 
casts  a  shadow  as  dense  as  that  cast  by  a  lead  plate  -^  of  an 
inch  thick. 

At  one  time  it  was  said  that  coating  with  vaselin  a  sur- 
face to  be  exposed  to  x-rays  would  protect  it  against  x-ray 
burns.  I  have  seen  x-ray  burns  occur  in  many  instances  under 
vaselin  and  other  ointments.  Lately  the  interposition  of  a 
layer  of  paraffin  has  been  suggested  for  the  same  purpose. 
This  suggestion  is  doubtless  a  lineal  descendant  of  the  vaselin 
idea,  and  is  absolutely  useless.  I  have  experimentally  produced 
x-ray  burns  under  a  coating  of  paraffin  y1^  of  an  inch  thick,* 
and  I  have  no  doubt  that  with  equal  ease  I  can  produce  a 
burn  under  a  layer  of  paraffin  of  \  inch  or  an  inch  in  thickness. 
Indeed,  I  think  it  may  be  stated  dogmatically  that  nothing 
will  prevent  x-ray  effects  upon  the  tissues  except  substances 
which  are  opaque  to  the  rays.  The  only  thing  necessary  to 
produce  x-ray  effects  upon  the  tissues  is  for  the  rays  themselves 
to  reach  the  exposed  surface. 

Aluminum  Screens. — The  only  suggestion  for  reducing  the 
likelihood  of  burns  in  surfaces  exposed  to  x-rays  that  is  of 
any  value  is  the  one  made  by  Elihu  Thomson,!  that  an  alumi- 
num screen  be  interposed  between  the  x-rays  and  the  exposed 
surface.  Thomson  suggested  the  aluminum  screen  on  the 
ground  that,  while  entirely  transparent  to  the  more  pene- 
trating rays,  it  would  absorb  the  softest  rays,  those  which  have 

*  Jour.  Am.  Med.  Assoc.,  1902,  xxxix,  p.  923. 

t  Boston  Med.  and  Surg.  Jour.,  1896,  cxxxv,  p.  610. 


330  TECHNIQUE    FOR    X-RAY    THERAPEUTICS. 

the  greatest  effect  upon  the  skin.  The  use  of  such  an  aluminum 
screen  of  the  thickness  of  -^  or  TJ  ff  of  an  inch  has  a  marked 
effect  in  preventing  dermatitis,  and  is  advisable,  in  my  opinion, 
in  making  all  exposures  for  therapeutic  purposes  except  where 
the  aim  is  to  produce  the  effect  solely  or  chiefly  on  the  skin. 
There  is  no  difficulty  in  producing  an  .r-ray  burn  through  an 
aluminum  screen.  I  have  produced  dermatitis  under  such  a 
screen  in  many  cases.  It  was  recommended  by  Tesla  *  that 
this  screen  be  grounded  in  order  to  prevent  burns.  As  I  have 
shown  by  experiment  on  page  290,  there  is  no  difficulty  in 
producing  a  burn  through  such  a  screen  even  when  grounded, 
and  I  believe  the  grounding  of  the  screen  to  be  useless. 

Insulation  of  Patient. — Kummell,t  working  in  the  opposite 
direction,  has  stated  that  the  influence  of  exposures  is  increased 
by  having  the  patient  sit  upon  an  insulated  stool.  There  is 
to  my  mind  no  reason  to  believe  that  such  insulation  has  the 
slightest  effect. 

;:  Electrical  Review,  Dec.  2,  1896. 
tArch.  f.  klin.  Chir.,  1898,  Ivii,  p.  630. 


CHAPTER  VI. 
TREATMENT  OF  X-RAY  BURNS. 

IN  connection  with  the  consideration  of  x-ray  exposures  for 
therapeutic  purposes,  we  may  well  consider  the  subject  of 
x-ray  burns,  since  it  is  often  necessary  to  carry  the  reaction 
to  the  point  of  producing  some  degree  of  burn  in  order  to  get 
the  desired  result,  and  since  it  may  at  times  be  impossible 
when  giving  x-ray  exposures  for  therapeutic  purpose  s  to  avoid, 
even  if  one  would,  x-ray  burns  of  more  or  less  severity. 

The  treatment  of  x-ray  burns  is  along  ordinary  medical  and 
surgical  lines.  The  burns  without  destruction  of  connective 
tissue  are  treated  by  the  soothing  applications  generally  used 
for  other  forms  of  dermatitis,  and  the  deep-seated  burns  are 
handled  in  the  same  way  as  other  sluggish  painful  ulcers  that 
show  little  tendency  to  heal.  In  a  general  way  one  has  to 
proceed  tentatively  in  the  treatment  of  x-ray  burns,  until  he 
finds  an  application  that  gives  relief.  In  burns  of  the  first  and 
second  degree  simple  dusting  powders  have  been  found  to  give 
most  relief  in  some  cases ;  in  others,  soothing,  mildly  astringent 
lotions ;  in  others,  salves  of  similar  properties  As  a  salve  base 
for  x-ray  burns  lanolin  was  suggested  first  by  Schiff  and  Freund,* 
and  it  seems  to  be  the  favorite.  According  to  Butler  and  Leonard, 
a  diachylon  ointment  made  with  lead  plaster  six  drachms  and 
cosmolin  two  drachms  is  a  very  soothing  base.  In  my  experience 
plain  vaselin,  rose  ointment,  or  equal  parts  of  lanolin  and  rose 
ointment  have  all  proved  of  use.  Leonard  t  recommends  for 
the  slight  degrees  of  burn  weak  solutions  of  liquor  plumbi 
subacetatis.  In  the  severer  forms  he  recommends  an  ointment 
containing  fifteen  grains  of  antipyrin  to  the  ounce  to  relieve 
pain.  In  the  case  reported  by  Cassidy  stearate  of  zinc  powder 
was  a  comfortable  application  for  the  dry  dermatitis.  On  the 

*Wien.  med.  Wochenschr.,  1898,  pp.  1057,  1118,  1177. 
f  American  X-ray  Journal,  1898,  iii,  p.  453. 
331 


332  TREATMENT    OF   X-RAY    BURNS. 

ulcerating  surface  ointments  afforded  relief,  but  any  poultice 
or  wet  dressing  of  whatever  nature  would  in  half  an  hour  or 
less  produce  the  most  agonizing  pain.  During  the  continuance 
of  the  slough,  which  in  this  case  was  accompanied  by  severe 
pain,  the  only  relief  was  from  large  doses  of  morphin.  Butler,* 
who  had  a  considerable  experience  in  treating  x-ray  burns, 
found  that  in  dermatitis  without  severe  ulceration  ichthyol 
and  lanolin,  equal  parts,  gave  relief.  In  another  case  relief 
was  obtained  from  hot,  wet  dressings  of  carbolic  acid  1  :  100. 
To  cause  softening  of  the  slough  he  used  with  satisfaction 
an  ointment  of  lead  plaster,  six  drachms ;  cosmolin,  two  drachms ; 
salicylic  acid,  ten  grains.  His  conclusions  as  to  treatment  are 
as  follows:  "  Pro  per  treatment  hastens  recovery  considerably, 
contrary  to  the  statement  of  Moullin  and  others.  Burns  of 
first  degree  are  benefited  by  the  continued  application  of 
ointments,  especially  having  a  lanolin  base.  Various  ointments 
and  drying  powders  increase  the  amount  and  thickness  of 
necrotic  membrane  in  burns  of  the  third  degree.  Hot,  moist, 
mildly  antiseptic  dressings  used  early  in  burns  of  second  and 
third  degree  help  to  limit  extent  of  ulceration,  and  used  late 
help  to  hasten  the  process  of  repair." 

Codman's  f  summary  of  treatment  of  severe  burns  is  as 
follows:  "Two  main  lines  of  treatment  may  be  mentioned  (a) 
physiological  rest  and  mild  poulticing;  and  (b)  excision,  followed 
by  skin  grafting.  The  first  should  be  used  at  least  until  the 
process  has  become  stationary  and  has  ceased  spreading;  the 
second,  only  when  the  pain  is  severe  and  rest  has  not  produced 
improvement." 

It  will  be  seen  from  the  foregoing  suggestions  of  various 
writers  that  the  treatment  presents  nothing  novel.  I  have  had 
considerable  experience  in  treating  x-ray  dermatitis  that  stopped 
short  of  ulceration  and  I  have  seen  nothing  to  indicate  that 
these  cases  should  not  be  treated  in  the  same  way  as  similar 
degrees  of  dermatitis  due  to  other  causes.  The  one  difficulty 
in  the  treatment  is  the  uncertainty  as  to  the  suitability  of 
any  application  in  a  given  case.  An  application  that  will  be 

*  American  Practitioner  and  News,  1900,  xxix,  p.  361. 
f  Phila.  Med.  Jour.,  1902,  ix,  p.  438. 


APPLICATIONS   FOR   X-RAY    BURNS.  333 

comfortable  in  one  case  will  irritate  the  next  similar  case,  so 
that  it  becomes  necessary  in  the  treatment  of  any  case  to 
proceed  tentatively  until  a  comfortable  application  is  found. 
The  best  indication  that  an  application  is  satisfactory  is  the 
fact  that  it  gives  relief,  and  per  contra  I  should  not  persist 
in  the  use  of  any  application  that  was  not  soothing.  In  dry 
dermatitis  the  use  of  a  light  inert  dusting  powder,  like  stearate 
of  zinc  or  talcum  and  boric  acid,  often  relieves  itching  and 
is  sufficient.  In  other  cases  more  comfort  is  obtained  from 
a  lotion.  The  well-known  calamin  and  zinc  oxid  lotion,  of 
the  following  formula,  I  have  found  very  useful : 

Calamin    •) 

Zinc  oxid  }      of  each>  one  ounce' 


Water one  pint, 

Glycerin 
Carbolic  acid 


Glycerin 

. ,  > of  each,  1  to  2  drachms. 

id  I 


In  some  of  these  cases  lead  and  opium  wash  has  proved  most 
comfortable,  usually  used  in  the  proportion  of— 

Tincture  of  opium      1  ounce, 

Subacetate  of  lead 1  ounce, 

Water q.  s.  a.  1  pint. 

Again,  I  have  found  exceedingly  soothing  in  some  cases 
applications  of  the  so-called  "liquor  Burrowii,"  a  solution  of 
aluminum  acetate  1  to  5  per  cent,  in  water.  I  have  found 
that  other  similar  cases  get  the  most  comfort  from  an  ointment 
such  as  lanolin  and  rose  ointment  equal  parts  with  a  drachm 
of  boric  acid  to  the  ounce.  Lanolin  alone  has  not  proved 
as  satisfactory  with  me  as  the  lanolin  mixture  described  above. 

In  cases  of  weeping  dermatitis  I  have  used  compresses  of 
lead  and  opium  most  frequently,  and  I  have  found  this  plan 
of  treatment  very  satisfactory.  In  other  cases  boric  acid  com- 
presses have  been  satisfactory  or  compresses  of  aluminum 
acetate,  or  ointments  such  as  those  mentioned  above.  I  have 
found  vaselin  and  boric  acid  a  good  application  in  many  cases, 
but  in  some,  in  which  it  was  irritating,  a  rose  ointment  or 
lanolin  and  rose  ointment  base  proved  soothing. 

In  the  lesions  accompanied  by  slough  the  relief  of  pain  is 


334  TREATMENT    OF   X-RAY    BURNS. 

the  first  indication.  Butler  *  has  used  orthoform  to  meet  this 
indication,  and  I  have  used  it  satisfactorily  in  combination 
with  compresses  of  lead  and  opium.  But  orthoform  should 
be  used  very  cautiously  about  x-ray  burns,  for  about  one 
patient  in  ten  will  get  up  a  dermatitis  under  orthoform  that 
might  cause  considerable  confusion  in  connection  with  an  x-ray 
burn.  Leonard  |  recommends  to  relieve  the  pain  an  ointment 
containing  3  per  cent,  antipyrin.  The  separation  of  the  slough 
in  these  cases  should  be  promoted  as  much  as  possible,  and 
be  followed  by  the  use  of  stimulating  applications,  very  cau- 
tiously applied  at  first.  In  certain  of  the  cases  in  which  the 
pain  is  very  severe  and  almost  no  tendency  to  recovery  exists, 
the  best  plan  of  treatment  is  excision  of  the  affected  area  and 
subsequent  skin  grafting.  This  has  been  done  successfully  in 
many  cases. 

Care  to  Avoid  Burns  in  X-ray  Workers. — Attention  has  been 
called,  while  considering  x-ray  burns,  to  the  chronic  x-ray 
effects  that  are  frequently  seen  in  x-ray  workers.  There  are  a 
surprisingly  large  number  of  x-ray  workers  who  have  suffered  from 
acute  x-ray  effects,  or  who  are  sufferers  from  chronic  x-ray  effects. 
Of  course,  there  is  no  way  for  persons  who  constantly  work 
around  x-ray  apparatus  to  avoid  the  effect  of  x-rays  upon 
the  tissues  except  by  carefully  avoiding  undue  exposure.  That 
this  can  be  done  has  been  demonstrated  by  the  experience 
of  myself  and  my  assistants,  none  of  whom  has  ever  suffered 
in  any  way  from  the  slightest  x-ray  burn.  Xo  precaution  of 
any  sort  has  been  taken  except  to  avoid  unnecessary  exposure 
to  the  rays.  The  habitual  practice  of  testing  tubes  by  the  use 
of  one's  hand  is  particularly  liable  to  lead  to  chronic  x-ray 
burns.  This  is  not  necessary,  and  the  habit  should  not  be 

contracted. 

» 

*  Am.  Pract.  and  News,  1900,  xxix,  p.  361. 
t  American  X-ray  Jour.,  1898,  iii,  p.  453. 


CHAPTER  VII. 

INDICATIONS  FOR  THE  THERAPEUTIC  USE  OF 
X-RAYS. 

FREUND,*  I  believe,  was  the  first  to  offer  any  generalization 
upon  this  subject.  He  suggested  the  use  of  x-rays  (a)  in  mycotic 
dermatoses ;  (6)  in  affections  of  the  skin  in  which  removal  of  the 
hair  is  of  importance  to  the  cure ;  (c)  in  certain  affections  where 
its  use  was  empirical.  Among  the  diseases  in  which  he  sug- 
gested its  use  were  lupus  vulgaris,  the  various  bacterial  diseases 
of  the  skin,  sycosis,  acne,  folliculitis,  furunculosis,  hypertrichosis, 
favus,  various  forms  of  tinea,  and  lupus  erythematosus. 

With  the  fuller  information  before  us  now  a  much  more 
accurate  statement  of  the  therapeutic  indications  can  be  made. 
The  effects  of  x-rays  which  offer  possibilities  of  therapeutic 
application  are  as  follows:  (I)  Their  effect  in  causing  atrophy 
of  the  appendages  of  the  skin ;  (II)  their  destructive  action  upon 
organisms  in  living  tissues ;  (III)  their  stimulative  action  upon 
the  metabolism  of  tissues ;  (IV)  their  power  of  destroying  certain 
pathological  tissues;  (V)  their  anodyne  effect. 

It  is  readily  seen  that  such  a  group  of  indications  offers 
great  possibilities  of  application.  It  is  also  evident  that  in 
many  affections  more  than  one  of  the  actions  of  the  agent 
may  come  into  play. 

As  a  corollary  to  the  above  it  may  be  stated  broadly  that 
x-rays  offer  a  possibility  of  use  in  the  following  groups  of 
affections : 

I.  Conditions  where  it  is  desired  to  remove  hair:  (a) 
hypertrichosis,  (6)  sycosis,  (c)  favus,  (d)  tinea  tonsurans,  (e) 
tinea  barba3  or  tinea  sycosis. 

II.  Where  it  is  desired  to  cause  atrophy  or  diminution 
in  size  or  functional  activity  of  the  sebaceous  glands:  (a) 
comedo,  (6)  acne,  (c)  acne  rosacea,  (d)  lupus  erythematosus  (?). 

*Wien.  klin.  Wochenschr.,  1900,  xiii,  p.  827. 
335 


336      INDICATIONS    FOR   THE    THERAPEUTIC    USE    OF   X-RAYS. 

III.  Where  it   is  desired  to  cause  atrophy  of  the  sweat- 
glands:   (a)  hyperidrosis. 

IV.  It  is  possible  that  they  might  be  of  use  also  where 
one  wanted  to   cause  exfoliation   of  the  nail  substance,   but 
as  far  as  I  know  such  an  application  of  x-rays  has  never  been 
made.     I  do  not  know  either  that  they  have  ever  been  tried 
in  hyperidrosis,   but  as   a   deduction   from  their  effect    upon 
the  sweat-glands,  I  have  previously  suggested  *  their  use  in 
intractable  forms  of  hyperidrosis. 

V.  Their  destructive  effect  upon  bacteria  in  tissues,  of 
course,  comes  into  play  in  a  number  of  the  affections  in  which 
their  use  is  suggested  above.  Such  a  quality  offers  possibilities 
of  the  widest  application  in  bacterial  diseases  of  the  skin. 
Their  use  in  lupus  vulgaris  is  the  most  brilliant  application 
in  bacterial  diseases  which  has  yet  been  made.  But  in  this 
condition,  doubtless,  their  effect  in  destroying  tissues  of  low 
resistance  is  of  greater  moment  than  the  germicidal  effect. 
Other  bacterial  diseases  in  which  they  have  been  used  success- 
fully, and  in  which  this  characteristic  is  an  important  factor,  are 
sycosis,  acne,  various  forms  of  tinea  and  favus,  and  eczema  (?). 
VI.  Their  stimulating  effect  upon  the  metabolism  of  the 
skin  offers  a  wide  field  of  application.  It  is  probably  this 
effect  that  explains  the  success  that  has  followed  their  use 
in  chronic  indurated  eczema,  lupus  erythematosus,  lichen 
planus,  psoriasis,  and  in  fact  in  the  entire  class  of  indurated, 
inflammatory  diseases  of  the  skin  in  which  stimulation  of 
the  tissues  is  necessary  in  order  to  cause  absorption  of  inflam- 
matory products. 

VII.  Their  power  of  causing  the  destruction  of  tissues  of 
low  resistance  without  the  destruction  of  the  healthy  stroma 
is  the  theoretical  indication  for  their  use  in  various  malignant 
diseases  and  in  other  processes  in  which  we  have  to  do  with 
cells  of  low  resistance.  Such  a  group  includes,  of  course,  most 
important  affections;  as  carcinoma  and  sarcoma,  tuberculosis, 
pseudo-leukemia,  and  leukemia. 

VIII.  Their  anodyne  effect  comes  into  play  in  the  treatment 
of  painful  malignant  and  inflammatory  conditions,  in  neuralgias 

*Jour.  Am.  Med.  Assoc.,  1901,  xxxvii,  p.  820. 


USE    OF    X-RAYS   NOT    EMPIRICAL.  337 

and  in  itching  dermatoses.  In  the  neuralgias  which  have  been 
reported  as  relieved  by  x-rays  it  is  probable  that  this  quality  of 
the  agent  alone  has  been  active. 

It  is,  of  course,  impossible  that  any  such  classification  as 
I  have  attempted  above  can  be  comprehensive  and  entirely 
accurate.  No  classification  can  be  entirely  satisfactory  until 
our  knowledge  of  the  pathology  of  disease  becomes  absolute, 
and  that  day  is  far  off.  The  attempt  at  classification  has  been 
made  in  order  to  show  in  a  general  way  the  possible  fields 
of  application  of  the  agent.  It  is  a  remark  one  constantly 
hears  that  the  use  of  x-rays  as  a  therapeutic  agent  is  entirely 
empirical;  that  in  working  with  them,  we  are  working  in  the 
dark,  and  that  there  are  as  yet  practically  no  definite  indications 
for  their  use.  I  believe  there  is  no  therapeutic  agent  against 
which  such*a  charge  can  less  justly  be  brought.  Observation  of 
their  clinical  effects,  and  microscopic  studies  of  tissues  under  the 
influence  of  x-rays,  have  furnished  us  rational  indications  for 
their  use  which  are  definite  and  positive.  There  is  no  thera- 
peutic application  of  x-rays  which  has  been  successfully  made 
that  is  not  in  consonance  with  our  present  knowledge  of  their 
effect  upon  tissues.  Their  use  as  a  therapeutic  agent  is,  in 
fact,  much  less  empirical  than  the  use  of  quinin  or  mercury 
or  arsenic  or  many  other  of  our  most  useful  remedies.  We 
have  some  knowledge  of  what  changes  take  place  in  the  cells 
under  x-rays,  and  no  man  can  yet  offer  as  accurate  a  descrip- 
tion of  the  changes  in  the  cells  produced  by  arsenic  or  mercury 
or  quinin. 

As  to  the  limits  of  usefulness  of  x-rays,  our  knowledge  is 
as  yet  far  from  complete.  Only  time  can  definitely  settle  such 
questions.  He  would  be  a  rash  man  who  would  make  any 
dogmatic  statements  upon  this  point,  but  within  certain  broad 
limits  speculation  is  possible.  It  will  probably  prove  true  in 
the  end  that  x-rays  can  only  be  curative  in  affections  circum- 
scribed sufficiently  to  get  direct  effect  of  the  rays  upon  the 
pathological  tissues  without  causing  destruction  of  the  over- 
lying and  surrounding  healthy  tissues.  A'-rays  will  probably 
prove  ineffectual  against  widely  distributed  metastases  of  ma- 
lignant diseases.  There  has  been  some  suggestion  that  the 
22 


338      INDICATIONS    FOR    THE    THERAPEUTIC    USE    OF   X-RAYS. 

destruction  of  the  cells  of  malignant  growths  and  other  patho- 
logical processes  liberates  toxins  or  antitoxins  which  may  be 
effective  against  other  foci  of  disease.  There  is  nothing  as 
yet  to  prove  that  such  is  the  case.  We  are  not,  however, 
in  position  to  dogmatize  as  to  the  limits  of  depth  at  which 
x-rays  may  be  effectual  against  malignant  growths.  Some 
well-established  findings  upon  this  point  are  extraordinary  and 
justify  the  persistent  attempt  to  use  z-rays  in  processes  which 
are  apparently  beyond  hope.  Before  we  determine  the  full 
limits  of  usefulness  of  the  agent,  there  will  be  doubtless  many 
disappointing  results.  There  is  reason  to  hope  that  there  will 
also  be  some  encouraging  ones. 


CHAPTER  VIII. 
DISEASES  OF  THE  APPENDAGES  OF  THE  SKIN. 

Hypertrichosis. — One  of  the  first  scientific  efforts  to  use  x-rays 
for  therapeutic  purposes  was  the  attempt  by  Freund  *  to  remove 
the  hairs  from  a  large  hairy  nrevus  by  their  use.f  This  first 
attempt  was  in  a  measure  successful,  and  it  led  to  his  subse- 
quent recommendation  of  the  method  for  the  treatment  of 
hypertrichosis. 

There  are  now  many  reports  in  the  literature  of  the  successful 
removal  of  hair  by  x-rays,  but  the  time  that  has  elapsed  between 

*Wien.  med.  Wochens.,  1897,  xlvii,  p.  428. 

t  The  queston  of  priority  in  the  therapeutic  application  of  ar-rays  lias  been, 
like  most  other  questions  of  priority,  a  matter  of  contention.  The  facts  in  the 
case  seem  to  be  these  : 

Despcignes,  1896  :  La  Semaine  Medicale,  July  29,  1896,  xvi,  p.  cxlvi,  under 
the  title  "  Cancer  de  1'estomac  ameliore  par  1'emploi  des  rayons  de  Kontgen," 
says:  "Dr.  Despeignes  has  had  occasion  recently  to  treat  by  x-rays  a  patient 
affected  with  cancer  of  the  stomach.  This  patient  was  exposed  twice  a  day  to 
the  x-light,  each  sitting  lasting  a  half  hour,  during  which  the  rays  from  a  pear- 
shaped  tube  were  directed  upon  the  gastric  neoplasm." 

Freund,  Jan.  15,  1897  :  At  a  meeting  of  the  k.  k.  Gesellschaft  der  Aerzte  at 
Vienna,  Jan.  15,  1897,  Freund  gave  his  first  report  on  the  x-ray  treatment  of  a 
nsevus  pigmentosus  pilosus.  This  report  was  published  in  the  Wiener  medi- 
zinische  Wochenschrift,  Mar.  6,  1897,  xlvii,  p.  428.  In  this  article  Freund  stated 
that  he  and  Schiff  were  about  to  undertake  further  experiments  on  the  effect  of 
x-rays  upon  the  other  conditions  of  the  skin.  In  a  subsequent  report  on  the 
same  case  (Wien.  med.  Wochens.,  May  18,  1897,  xlvii,  p.  856),  Freund  suggested 
the  use  of  x-rays  in  sycosis  and  favus. 

Rendu  and  Du  Castel,  Jan.  17,  1897  :  Rendu  and  Du  Castel,  Bulletin 
Me"dicale,  Jan.  17,  1897,  reported  the  employment  of  the  x-rays,  at  the  request 
of  the  patient's  father,  in  a  case  of  bronchopneumonia  ;  55  sittings  were  given, 
with  apparently  favorable  result. 

Kummell,  April  22,  1897  :  At  the  twenty-second  Congress  of  the  Deutsche 
Gesellschaft  fur  Chirurgie,  April  22,  1897,  Kummell  reported  the  results  ob- 
tained by  himself  and  his  associate,  Gocht,  in  lupus.  This  report  was  embodied 
in  his  article,  "Die  Bedeutung  der  Rontgenstrahlen  fur  die  Chirurgie,"  pub- 
lished in  the  Centralblatt  fur  Chirurgie,  July  17,  1897,  xxiv,  Beilage  p.  18. 

Schiff,  Aug.  25,  1897:  At  the  Twelfth  International  Medical  Congress  at  Mos- 
cow, Aug.  25,  1897,  Freund  reported  his  experiments  on  the  removal  of  hair  by 

339 


DISEASES    OF   THE    APPENDAGES   OF   THE    SKIX. 

the  removal  of  the  hair  and  the  reports  in  many  cases  is  not 
sufficient  to  allow  of  conclusion  as  to  the  permanency  of  the 
results.  Reports  of  results  more  or  less  successful  have  been 
made  by  Schiff  and  Freund,*  Benedikt,f  Walsh,  J  Ehrmann,  § 
Sharp,  |1  Wood,**  Meek,ft  Starting  {  Hahn,§§  Sjogren  and 
Sederholm,  ||  |i  Gocht,***  Beck,ftt  Torok  and  Schein,  +  +  + 
Jutassy,§§§  and  others. 

Schiff  and  Freund,  to  whom  is  due  the  credit  of  the  intro- 
duction of  the  method,  reported  in  1898  six  cases  treated 
successfully  by  this  method.  Their  conclusions  from  these 
cases  were  briefly  as  follows: 

The  best  results  are  obtained  after  seventeen  to  thirty  ex- 
posures. The  only  signs  of  reaction  produced  are  a  slight 
temporary  erythema  or  pigmentation  occurring  shortly  before 

x-rays;  and  in  his  report  he  included  at  Schiff's  request  a  report  on  Schiff's  treat- 
ment of  lupus,  stating  that  Schiff's  article  on  the  subject  would  appear  later. 

Gocht,  Sept.,  1897:  In  the  first  number  of  the  Fortschritte  an  dem  Gebiete 
der  Roentgenstrahlen,  the  date  of  publication  of  which  is  given  by  the  editors 
as  September,  1897,  Gocht  published  a  fairly  comprehensive  article  on  the  ar-ray 
treatment  of  six  cases  of  lupus,  two  cases  of  mammary  cancer,  one  case  of 
nsevus  pilosus,  one  case  of  trigeminal  neuralgia,  and  one  case  of  removal  of  hair 
from  an  obstinate  wound.  He  stated  in  this  article  that  Dr.  Kiimmell  had 
already  reported  their  experiments  at  the  Surgical  Congress  of  that  year. 

For  real  priority  in  the  whole  field  of  phototherapy  and  radiotherapy  it  seems, 
however,  that  we  must  go  back  about  five  hundred  years,  according  to  the  fol- 
lowing statement  from  the  Polyclinic  for  April,  190:2  (N.  Y.  Med.  Jour.,  1902, 
Ixxvi,  p.  766). 

"So  early  as  the  fourteenth  century  John  of  Gaddesden,  the  author  of  the 
treatise  '  Rosa  Medicinse.,'  treated  the  son  of  King  Edward  I  for  variola  by  en- 
veloping him  in  a  robe  of  scarlet  and  placing  him  in  a  bed  hung  with  scarlet 
curtains,  in  a  room  also  curtained  in  scarlet.  The  patient  recovered  without 
any  marks  of  smallpox." 

*Wien.  med.  Wochens.,  1898,  xlviii,  p.  1058. 

f  Wien.  med.  Wochens.,  1901,  li,  p.  517.  J  Lancet,  1901,  ii,  p.  1191. 

\  Wien.  med.  Wochens.,  1901,  li,  p.  1466. 

||  Archives  of  the  Rontgen  Ray,  1900,  iv,  p.  52.         **  Lancet,  1900,  i.  p.  2:51. 

ft  Boston  Med.  and  Snrg.  Jour.,  1902,  cxlvii,  p.  152. 

it  Lancet,  1901,  i,  p.  654  ;  and  1901,  ii,  p.  1375. 

H  Wien.  med  Wochens.,  1901,  xxvii,  V.  B.  p.  29. 

Illl  Fortschr.  a.  d.  Geb.  d.  Rontgenstrahlen,  1901,  iv,  p.  145. 

***  Fortschr.  a.  d.  Geb.  d.  Rontgenstrahlen,  1897,  i,  p.  14. 

ttt  Med.  Record,  1902,  Ixi,  p.  83. 

tJt  Wien.  med.  Wochens.,  1902,  lii,  p.  847. 

\\\  Ungar.  med.  Presse,  1398,  iii,  p.  33. 


HYPERTRICHOSIS.  341 

the  falling  of  the  hair  and  vanishing  in  three  or  four  days.  In 
some  brunettes  the  hair  becomes  snow-white  before  falling  out. 

In  a  further  report  in  1900  *  they  state  as  a  result  of  their 
experience  that  the  treatment  "frees  surfaces  from  growths  of 
hair,  no  matter  how  thick,  within  a  few  weeks,  and  completely, 
thus  offering  at  the  beginning  of  treatment  a  result  obtained 
by  means  of  electrolysis  only  after  years  of  trouble.  The 
secondary  treatment  is  intermittent  and  requires  the  presence 
of  the  patient  only  at  definite  intervals  for  a  few  days.  For 
small  hairy  warts  and  moles  we  give  the  preference  to  electrol- 
ysis; for  large  surfaces,  however,  unhesitatingly  to  the  x-rays." 

Holzknecht  f  has  reported  favorable  results  in  hypertrichosis 
with  a  close  or  heavy  growth  of  hair.  He  does  not  recommend 
the  treatment  for  young  persons  with  a  fine  growth  of  hair, 
on  account  of  the  atrophy  of  the  skin  which  is  caused. 

Jutassy  has  reported  forty  cases  treated  by  this  method, 
and  concludes  from  his  experience  that  permanent  alopecia 
may  be  attained.  Some  of  his  cases  have  shown  no  recurrence 
after  a  year.  Lasting  alopecia  may  be  expected,  in  his  opinion, 
only  after  repeated  production  of  the  condition  of  hyperemia. 

Neville  Wood  reported  one  case  of  removal  of  thick  dark 
hairs  from  the  chin,  in  which  eight  months  after  the  cessation 
of  treatment  parts  which  had  had  dermatitis  remained  quite 
free  from  hairs. 

Startin  reported  four  cases  of  hypertrichosis  successfully 
treated  by  x  -rays.  Eighteen  months  later  he  reported  that 
there  had  been  no  recurrence  in  any  of  these  cases.  And  he 
reported,  further,  that  he  had  treated  forty  other  cases  of 
hypertrichosis  which  are  "as  nearly  relieved  as  can  be."  In 
each  of  these  cases  there  had  been  slight  dermatitis. 

Sjogren  and  Sederholm  have  reported  the  treatment  of  ten 
cases  of  hypertrichosis,  and  conclude  that  there  is  no  question 
that  repeated  exposures  will  destroy  the  hair  follicles,  the 
practicability  of  the  treatment  depending  upon  the  size  of  the 
area  to  be  affected.  For  a  comparatively  small  number  of 
hairs  some  other  method  is  preferable. 

*Wien.  klin.  Wochens.,  1900,  xiii,  p.  827. 

fHavas:  Arch.  f.  Derm.  u.  Syph.,  1900,  Festschrift  Kaposi,  p.  275. 


342  DISEASES    OF   THE    APPENDAGES    OF    THE    SKIN. 

I  have  treated  fourteen  cases  of  hypertrichosis  by  this  method 
as  follows: 

Case  1. — Miss ,  aged  twenty-five,  with  dark  hair  and 

fair  skin,  with  profuse  growth  of  dark  hairs  on  both  arms. 
Began  treatment  February  1,  1900.  She  had  thirty-eight 
exposures  on  either  arm  between  February  1  and  March  17. 
On  March  19  there  was  some  burning  and  irritation  "like  sun- 
burn." A  few  days  later  mild  dermatitis  developed  which 
subsided  hi  the  course  of  a  week,  and  with  its  disappearance 
the  hairs  on  the  back  of  the  arms  came  out.  Against  her 
wishes  she  was  unable  to  have  further  treatment,  and  there 
was  a  recurrence  of  a  great  part  of  the  growth,  though  the 
condition  is  improved. 

Case  2. — Miss ,  aged  twenty-two,  with  black  hah*  and 

moderately  fair  skin.  There  was  a  profuse  growth  of  very 
coarse  black  hairs  on  the  chin  and  upper  lip.  The  growth 
tinder  the  chin  practically  amounted  to  a  beard,  and  was  not 
less  than  that  seen  in  many  men  of  the  same  age.  During 
July,  August,  and  September,  1900,  she  received  forty  sittings. 
After  twenty-five  sittings  slight  erythema  appeared,  which 
subsided  after  a  few  days'  respite  from  treatment.  This  ery- 
thema recurred  twice  and  quickly  subsided  each  time.  It  was 
noted  that  the  first  evidence  of  reaction  was  always  the  turning 
white  of  the  hairs.  After  the  development  of  the  first  erythema 
the  hairs  began  to  come  out.  During  November  and  December 
she  received  twenty-five  treatments,  and  on  December  14  an 
acute  dry  dermatitis  developed.  The  skin  became  quite  tender, 
but  the  dermatitis  subsided  without  vesiculation  at  the  end 
of  twro  weeks,  and  with  its  subsidence  practically  all  of  the 
hairs  came  out.  Since  that  time,  January,  1901,  there  has  never 
been  a  marked  return  of  hair,  though  a  few  hairs  recurred, 
and  at  intervals  of  three  to  five  months  she  has  had  a  few 
exposures  for  the  removal  of  recurrent  hairs.  She  had  ten 
exposures  in  February,  1902,  to  remove  a  few  remaining  hairs 
on  her  chin.  Since  January,  1901,  there  have  been  practically 
no  disfiguring  hairs  on  her  face,  and  there  has  never  been  at 
any  time  return  of  more  than  a  few  hairs.  The  result  in  this 
case  may  be  regarded  as  entirely  satisfactory,  though  it  was 


HYPERTRICHOSIS.  343 

attained  at  the  expense  of  an  irritation  which  at  the  time  of 
its  occurrence  caused  me  much  anxiety. 

Case  3  — Mrs.  ,  aged  thirty-five,  with  brown  hair 

and  moderately  fair  skin  and  with  a  profuse  growth  of  long, 
coarse  hairs  under  the  chin  and  on  the  upper  lip,  and  down 
over  the  cheeks.  Treatment  was  begun  August  1,  1900.  Be- 
tween August  1  and  November  27  sixty-six  exposures  were 
given.  During  this  time  slight  erythema  developed  on  several 
occasions,  accompanied  by  the  outfall  of  some  hair.  A  rest 
for  the  erythema  to  disappear  was  allowed  at  each  time  of 
its  occurrence.  By  January  1,  1901,  the  face  was  practically 
free  from  hah*.  There  was  slight  pigmentation  and  slight 
wrinkling  of  the  skin  around  the  corners  of  the  mouth.  By 
June,  1901,  there  had  been  a  considerable  return  of  hair,  and 
in  July  and  August,  1901,  she  had  fifteen  sittings  for  the  re- 
moval of  these  hairs.  Since  that  time  she  has  had  two  series 
of  exposures  of  ten  to  fifteen  sittings  each,  but  at  present  there 
is  some  recurrence  of  hairs.  In  this  case  the  hairs  began  to 
recur  before  the  entire  disappearance  of  the  pigmentation.  At 
the  present  time  there  is  a  considerable  return  of  hair  and 
the  case  cannot  be  called  a  success.  The  number  of  hairs  is 
very  considerably  diminished,  sufficiently  so  to  satisfy  the 
patient,  but  the  result  is  not  satisfactory.  The  slight  erythema 
and  pigmentation  in  this  case  at  one  time  persisted  for  several 
months. 

Case  4. — Miss ,  aged  twenty-five,  with  dark  hair  and 

medium  complexion.  This  patient  was  a  niece  of  the  patient 
in  Case  3,  and  the  course  and  result  of  treatment  were  almost 
identical.  The  growth  of  hair  was  not  so  marked  and  the  result 
is  somewhat  better,  but  there  has  been  some  return  of  hair. 
This  case  was  treated  at  practically  the  same  time  as  Case  3, 
and  has  had  no  treatment  since  January,  1902. 

Case  5. — Miss ,  aged  twenty-eight,  with  fair  hair  and 

medium  complexion.  She  had  a  growth  of  long  coarse  hairs, 
many  of  them  more  than  an  inch  long,  under  the  chin,  and 
a  similar  growth  not  so  marked  on  the  upper  lip  and  cheeks. 
Treatment  began  October,  1900.  After  thirty-three  exposures 
some  dermatitis  developed,  and  the  hairs  came  out  in  December, 


344  DISEASES   OF   THE   APPENDAGES   OF   THE    SKIN. 

1900.  By  the  middle  of  February,  1901,  some  hairs  had  re- 
curred and  were  removed  in  twelve  sittings.  By  the  middle 
of  June  some  hairs  had  recurred  again,  and  were  removed  in 
fifteen  sittings.  By  the  middle  of  November,  1901,  a  consider- 
able number  of  hairs  had  recurred  and  were  removed  in  twenty 
sittings.  In  March,  1902,  there  had  been  some  recurrence  of 
hairs  and  she  was  given  eleven  sittings.  These  exposures  were 
followed  by  a  rather  acute  weeping  dermatitis,  although  the 
previous  treatments  had  never  been  accompanied  by  more  than 
a  moderate  dry  dermatitis  and  had  produced  practically  no 
pigmentation.  This  dermatitis  disappeared  in  six  weeks,  but 
the  patient  had  two  subsequent  slight  returns  of  dermatitis 
over  this  area.  The  face  at  the  present  time  is  free  from  hair 
except  for  a  few  inconspicuous  short  hairs  under  the  chin. 
The  condition  of  the  skin  is  slightly  atrophic  around  the  sides 
of  the  chin,  but  not  conspicuously  so. 

In  the  succeeding  cases  the  treatment  has  been  carried  out 
in  much  the  same  way  as  in  those  given  above  as  regards  the 
number  of  exposures,  the  repetitions  of  treatment,  and  the 
intensity  of  the  light.  Therefore  these  details  will  not  be 
repeated. 

Case  6. — Mrs.  ,  aged  thirty-five,  with  brown  hair  and 

medium  complexion,  and  with  a  profuse  growth  of  not  very 
coarse  hairs  under  chin  and  on  upper  lip.  Treatment  in  this 
case  began  in  January,  1901.  She  has  been  treated  persist- 
ently, with  removal  of  the  hair  on  three  occasions.  There  has 
always  been  considerable  return  of  hair,  however,  and  the 
removal  of  the  hair  has  been  accompanied  by  a  good  deal 
of  pigmentation.  There  is  some  improvement  in  the  hyper- 
trichosis  at  present,  but  the  return  of  hair  has  been  considerable, 
and  the  result  cannot  be  regarded  as  satisfactory. 

Case  7. — Miss .  aged  twenty-six,  with  black  hair  and 

dark  skin,  and  with  abundant  growth  of  long,  coarse,  black 
hairs  under  the  chin,  on  the  upper  lip,  and  on  the  cheeks. 
This  patient  began  treatment  in  January,  1901.  In  the  reaction 
to  x-rays  this  case  has  been  markedly  similar  to  Case  0.  The 
hairs  on  the  cheeks  and  upper  lip  are  no  longer  sufficient  to 
be  disfiguring,  but  there  are  still  some  coarse  hairs  that  tend 
to  recur  under  the  chin. 


HYPERTRICHOSIS.  345 

Case  8. — Mrs.  ,  aged  forty-eight,  with  black  hair  and 

dark  skin,  and  with  a  very  abundant  growth  of  coarse  black 
hairs  on  upper  lip,  chin,  and  cheeks.  The  hypertrichosis  in 
this  case  was  excessive;  the  hairs  were  very  coarse  and  black, 
and  under  the  chin  were  an  inch  or  more  long.  Treatment 
was  begun  April  29,  1901,  and  the  hair  was  satisfactorily  re- 
moved. She  has  had  several  subsequent  series  of  exposures. 
After  each  removal  there  has  been  some  recurrence  of  coarse 
hairs,  but  their  number  has  gradually  diminished.  At  present 
there  is  a  return  of  a  few  hairs,  but  their  number  is  much  less. 
This  patient,  without  having  at  any  time  a  marked  derma- 
titis, has  shown  a  good  deal  of  pigmentation,  and  there  has 
been  considerable  wrinkling  of  the  skin.  The  present  condition, 
while  a  decided  improvement,  cannot  be  called  a  satisfactory 
result. 

Case  9. — Miss  ,  aged  thirty,  with  dark  hair  and  fair 

skin  and  with  an  abundant  growth  of  long  down  over  the 
cheeks  and  under  the  chin.  The  patient  was  treated  during 
the  summer  of  1901  with  satisfactory  results.  All  of  the  hairs 
from  the  cheeks  and  under  the  chin  disappeared  without  a 
severe  reaction  being  produced,  and  although  the  patient  had 
no  treatment  from  September,  1901,  to  June,  1902,  there  was 
only  the  return  of  a  small  amount  of  down  on  the  cheeks, 
not  sufficient  to  cause  annoyance.  There  was  during  the  sum- 
mer of  1902  a  return  of  a  few  hairs  under  the  chin,  which 
were  removed. 

Case  10. — Miss ,  aged  twenty-five,  with  dark  hair  and 

fair  skin,  and  with  down  on  upper  lip  and  cheeks.  This  case 
had  more  persistent  treatment  than  No.  9,  but  in  its  course 
and  in  its  results  is  very  similar.  Treatment  was  begun  in 
May,  1901.  The  hairs  were  removed  satisfactorily  over  all  the 
areas  in  October,  1901.  She  has  had  several  periods  of  treat- 
ment since  that  time,  but  there  has  been  no  marked  recurrence 
of  hair,  and  there  is  only  a  very  small  quantity  of  down  upon 
the  face. 

Case  11. — Miss  ,  aged  twenty-six,  with  light  brown 

hair  and  medium  complexion,  and  with  growth  of  long,  coarse, 
light  brown  hairs  under  chin,  and  down  on  upper  lip  and  cheeks. 


346  DISEASES    OF   THE    APPENDAGES    OF   THE    SKIN. 

Treatment  began  June,  1901,  and  the  hairs  were  removed,  in 
this  case  in  the  summer  of  1901,  and  have  not  shown  marked 
tendency  to  recur.  She  has  had  several  periods  of  treatment 
since  that  time.  At  present,  after  four  months  without  treat- 
ment, there  is  a  slight  recurrence  of  hair  on  the  upper  lip,  but 
at  no  time  has  there  been  a  marked  recurrence  of  the  down 
on  the  cheeks,  or  of  the  long  hairs  under  the  chin,  where  the 
treatment  was  most  vigorous. 

Case  12. — Mrs.  ,  aged  forty-two,  with  dark  hair  and 

fair  skin  and  with  growth  of  fine  hairs  under  chin  and  on  upper 
lip.  This  case  is  very  similar  to  Cases  9  and  10.  Treatment 
began  in  October,  1901,  and  the  hairs  were  satisfactorily  re- 
moved. There  has  been  no  treatment  since  March,  1902,  and 
the  condition  is  distinctly  improved,  while  there  is  still  some 
down. 

Case  13. — Mrs. ,  aged  fifty,  with  dark  hair  and  medium 

complexion  and  with  abundant  growth  of  fairly  long  hairs 
under  the  chin,  and  profuse  growth  of  long  down  on  upper 
lip  and  cheeks.  The  case  is  very  similar  to  Case  11.  The 
treatment  in  this  case  has  been  accompanied  by  a  gradual 
shedding  of  the  hair,  but  there  has  been  at  times  considerable 
pigmentation  and  always  some  recurrence  of  hairs.  At  the 
present  time  the  condition  of  hypertrichosis  is  somewhat  im- 
proved, but  not  markedly  so.  The  general  condition  of  her 
skin  is  distinctly  improved. 

Case  14. — Mrs. ,  aged  thirty-eight,  with  dark  hair  and 

fair  skin,  and  with  a  considerable  growth  of  down  on  chin 
and  cheeks  and  upper  lip.  This  was  removed  in  February, 
March,  and  April,  1902,  and  has  shown  only  slight  tendency 
to  return,  except  on  the  upper  lip,  which  is  but  little  improved. 

In  this  connection  I  may  mention  the  removal  of  the  hairs 
from  a  large  pigmented  hairy  naevus  over  the  right  eye  of  a 
baby.  In  this  case  the  hair  was  satisfactorily  removed,  leaving 
an  eyebrow  of  good  shape.  There  has  been  only  a  slight  ten- 
dency to  recurrence,  the  pigmentation  has  been  greatly  dimin- 
ished, and  the  skin  is  smooth  and  normal-looking. 

As  will  be  seen,  the  results  in  these  cases  are  not  uniform. 
Case  2  may,  I  think,  be  put  down  as  an  unqualified  success. 


HYPERTRICHOSIS.  347 

Case  5  also  shows  a  satisfactory  result.  Case  1  shows  improve- 
ment, but  there  were  not  enough  treatments  to  give  the  method 
a  fair  trial.  Cases  9,  10,  12,  and  14,  all  of  which  showed  very 
slight  degrees  of  hypertrichosis,  have  shown  distinct  improve- 
ment, and  the  results  are  satisfactory  to  the  patients,  the 
most  critical  judges  in  such  cases.  Case  11  has  been  distinctly 
improved,  and  Case  12  also  improved,  though  to  a  less  degree. 
In  Case  8  there  has  been  a  marked  decrease  in  the  number 
of  hairs,  but  those  that  remain  are  still  distinctly  conspicuous, 
and  whether  or  not  the  result  justifies  the  treatment  is  in  my 
mind  a  matter  of  doubt.  Cases  3,  4,  6,  and  7  have  not  shown 
sufficient  improvement,  in  my  opinion,  to  justify  the  treatment. 

The  condition  in  which  the  skin  of  the  parts  treated  has 
been  left  is  worthy  of  brief  consideration.  In  Cases  2,  11, 
and  13  the  appearance  of  the  skin,  aside  from  the  removal 
of  the  hair,  has  been  distinctly  improved.  In  Case  11  there 
was  a  severe  acne  of  the  chin,  which  has  not  recurred  in  a 
year.  None  of  these  cases  shows  more  than  very  slight  atrophy 
of  the  skin  around  the  corners  of  the  mouth,  and  this  is  not 
noticeable.  In  Cases  9,  10,  12,  and  14  all  the  patients  had 
good  complexions  at  the  time  treatment  was  begun,  and  this 
condition  has  not  been  changed  by  the  treatment.  In  Case 
12  there  was  noted  the  appearance  of  two  or  three  faint  wrinkles 
at  the  corners  of  the  mouth.  In  Cases  3,  4,  6,  and  7  decided 
pigmentation  occurred,  which  for  a  time  was  apparent,  but 
not  more  conspicuous  than  the  ordinary  tan  of  summer.  The 
skin  of  the  chin  in  Case  3  showed  for  several  months  considerable 
irritation.  In  Case  8  the  wrinkling  of  the  skin  as  the  result 
of  the  removal  of  so  many  coarse  hairs  is  quite  perceptible, 
and  is  sufficient  to  be  given  some  weight  in  considering  the 
result.  In  Case  5  the  skin  remained  quite  irritable  for  several 
months  after  the  dermatitis,  with  two  recurrent  attacks  of 
acute  dermatitis  which  were  for  a  time  very  annoying.  The 
permanent  condition  of  the  skin  in  this  case,  though  there  is 
slight  atrophy,  is  not  unsatisfactory,  and,  taken  in  connection 
with  the  disappearance  of  the  hair,  is  a  great  improvement. 

It  is  evident  that  the  reaction  required  to  cause  removal 
of  the  hair  has  varied  very  considerably  in  different  individuals. 


348  DISEASES    OF   THE    APPENDAGES    OF   THE    SKIN. 

In  Cases  1,  3,  4,  6,  7,  9,  10,  11,  12,  13,  and  14  there  has  never 
been  more  than  slight  dry  dermatitis  In  some  of  these  cases 
it  has  been  very  slight,  but  I  have  never  seen  the  hairs  dis- 
appear in  any  case  without  the  production  of  some  erythema, 
and  I  have  made  persistent  and  patient  attempts  to  attain 
the  outfall  of  the  hair  without  any  inflammatory  reaction.  In 
Cases  2  and  5  quite  acute  dermatitis  was  produced,  and  the 
results  in  these  two  cases  are  more  radical  than  in  any  others. 
My  experience  is  in  accord,  therefore,  with  those  writers  who 
report  that  to  get  alopecia  some  dermatitis  is  required,  and 
that  the  result  is  more  permanent  when  the  dermatitis  is  con- 
siderable. 

From  my  experience  I  am  of  the  opinion  that  the  treatment 
of  hypertrichosis  by  the  use  of  x-rays  is  only  a  qualified  success. 
I  think,  from  the  consideration  of  my  cases  and  other  cases 
in  the  literature,  that  there  can  be  no  question  that  hair  can 
be  permanently  removed  in  some  cases  by  repeated  x-ray 
exposures  without  damage  to  the  skin.  On  the  other  hand, 
it  is  probable  that  in  some  cases  a  satisfactory  result  cannot 
be  obtained.  It  is  an  indisputable  fact  that  in  addition  to 
the  removal  of  the  hair  there  will  be  a  distinct  improvement 
in  the  skin  in  some  cases.  This  is  particularly  noticeable 
where  the  skin  is  profusely  supplied  with  sebaceous  glands. 
The  slight  atrophy  of  the  skin  that  accompanies  the  successful 
removal  of  hairs  is  in  a  few  cases  of  sufficient  extent  to  detract 
somewhat  from  completely  satisfactory  cosmetic  results,  but 
in  most  cases  this  is  not  important.  I  have  not  found,  as 
Holzknecht  suggests,  that  this  atrophy  is  of  more  importance 
in  young  patients  than  in  older  ones.  Indeed,  the  only  atrophy 
that  I  have  seen  that  is  worthy  of  mention  has  been  in  my 
oldest  patient. 

Considering  the  difficulties  in  the  way  of  carrying  out  this 
treatment,  it  is  to  be  recommended  only  in  those  cases  in  which 
a  large  number  of  hairs  need  to  be  removed  Where  only  a 
few  hairs  are  to  be  removed  electrolysis  is  the  better  method. 
Electrolysis,  however,  is  notoriously  inadequate  for  the  removal 
of  a  profuse  growth  of  hair,  and  in  such  cases  the  use  of  x-rays 
is  to  be  considered.  The  method  is  so  tedious  and  so  beset 


ALOPECIA   ARE  ATA.  349 

with  difficulties  that  I  hesitate  to  advise  it  except  in  cases 
of  hypertrichosis  of  exaggerated  type.  There  is,  however,  in 
my  opinion  no  objection  to  its  application  in  any  case,  however 
slight,  in  which  the  patient  is  urgent  for  relief.  The  greatest 
difficulty  in  connection  with  this  treatment  of  hypertrichosis  is 
that  one  is  treating  a  purely  cosmetic  defect,  and  therefore 
must  stay  well  within  the  bounds  of  safety.  But  to  cause  a 
sufficient  atrophy  of  the  hair  follicles  to  produce  alopecia  a 
very  considerable  x-ray  effect  must  be  attained,  and  to  do 
this  without  causing  an  undesirable  degree  of  dermatitis  is  a 
problem  of  the  greatest  nicety.  There  is  no  therapeutic  appli- 
cation of  x-rays,  I  am  sure,  which  requires  so  much  caution 
and  skill  as  does  the  removal  of  hair.  And  I  believe  one  should 
not  undertake  it  until  he  has  had  considerable  experience 
with  his  particular  apparatus  in  the  treatment  of  other  affec- 
tions. 

Alopecia  Areata. — The  treatment  of  alopecia  areata  by  x-rays 
has  been  reported  by  Kienbock  *  and  Holzknecht.f  Kienbock 
has  reported  a  case  in  a  young  man,  of  three  years'  duration, 
in  which  two  months  after  x-ray  exposures  dark-colored  normal 
hairs  appeared  on  the  surface  treated,  while  on  surfaces  that 
had  not  been  treated  the  growth  of  hairs  did  not  occur. 

Holzknecht  has  used  the  method  with  some  success  in  several 
cases.  One  case  he  has  described:  A  boy  aged  eighteen  had 
alopecia  areata  that  had  progressed  steadily  for  five  months. 
There  was  a  fine  growth  of  hair  after  six  months'  treatment 
with  x-rays. 

Alopecia  areata  is  a  disease  so  irregular  in  its  course  that 
one  must  be  very  cautious  in  drawing  conclusions  as  to  the 
utility  of  any  method  of  treatment.  In  the  cases  of  alopecia 
areata  which  are  mycotic  in  origin — and  in  all  probability  there 
are  many  such  cases — it  is  possible  that  x-rays  may  prove  of 
use,  and  in  cases  of  tinea  tonsurans  simulating  alopecia  areata 
this  treatment  would  probably  be  successful.  In  the  cases 
which  are  not  mycotic — and  in  the  light  of  our  present  knowledge 
probably  many  of  them  are  not — it  is  hard  to  say  how  x-rays 

*Wien.  klin.  Wochens.,  1900,  xiii,  p.  1053. 
fWien.  klin.  Wochens.,  1900,  xiii,  p.  1177. 


350  DISEASES    OF   THE    APPENDAGES    OF   THE    SKIN. 

could  be  of  any  more  service  than  other  stimulants.  The  fact, 
however,  that  x-rays  cause  temporary  atrophy  of  the  follicles 
is  not  a  valid  reason  for  believing  that  they  would  be  contra- 
indicated  in  alopecia  areata,  for  unless  an  x-ray  reaction  is 
produced  several  times  the  healthy  hair  follicles  regenerate. 
It  is  barely  possible  that  the  effect  of  x-rays  upon  the  tissues 
in  alopecia  areata  would  tend  in  the  end  to  a  regeneration 
of  the  hair  follicles.  All  this,  however,  is  speculation,  and  it 
will  require  a  very  much  larger  experience  in  alopecia  areata 
than  we  yet  have  to  furnish  a  basis  for  any  opinion  as  to  the 
use  of  x-rays  in  that  disease. 

Tinea  Tonsurans  and  Favus. — The  use  of  x-rays  in  the  treat- 
ment of  tinea  tonsurans  and  favus  was  suggested  by  Freund.* 
Cases  of  tinea  tonsurans,  successfully  treated  by  x-rays,  have 
been  reported  by  Schiff  and  Freund,t  Kienbock,  £  Torok  and 
Schein,§  and  others.  Cases  of  favus  successfully  treated  have 
been  reported  by  Schiff  and  Freund, f  Hahn  and  Albers-Schon- 
berg,  ||  Torok  and  Schein,§  Kienbock, :{:  and  others.  One  of 
Schiff  and  Freund 's  cases  has  remained  cured  for  a  year.  In 
these  cases  the  reaction  has  to  be  carried  to  the  point  of  causing 
complete  alopecia  and  slight  inflammatory  reaction  of  the  skin. 
Theoretically  the  treatment  is  ideal.  It  causes  outfall  of  the 
diseased  hairs,  and  at  the  same  time  destroys  the  organisms 
upon  which  the  disease  is  dependent.  The  alopecia  which  it 
causes  is  temporary  unless  it  is  accompanied  by  a  greater 
reaction  in  the  skin  than  is  necessary.  The  practical  objections 
to  the  method  are,  in  the  first  place,  that  it  is  tedious;  and, 
in  the  second,  that  x-ray  exposures  of  as  large  a  part  of  the 
scalp  as  is  necessary  in  the  treatment  of  the  usual  case  of  tinea 
tonsurans  or  favus  is  a  procedure  of  some  risk  unless  carried 
out  with  caution. 

All  that  is  said  concerning  the  method  in  the  treatment  of 
tinea  tonsurans  applies  with  equal  weight  to  the  treatment  of 
favus. 

*  "\Vien.  med.  TVochens.,  1897,  xlvii,  p.  856. 

fFortschr.  a.  d.  Geb.  d.  Rontgenstrahlen,  1899,  iii,  p.  109. 

iArch.  f.  Derm.  u.  Syph.,  1901,  Ivi,  p.  132. 

\  Wien.  med.  Wochens.,  1902,  Iii,  p.  847. 

|i  Munch,  med.  Wochens.,  1900,  xlvii,  pp.  284,  C24,  363. 


SYCOSIS.  351 

The  method  may  prove  a  very  much  needed  addition  to  the 
therapy  of  these  diseases. 

Sycosis. — The  treatment  of  sycosis  by  z-rays  was  suggested 
and  first  carried  out  by  Schiff  and  Freund,*  and  there  are 
numerous  reports  in  the  literature  testifying  to  its  success. 
Successful  cases  have  been  reported  by  Hahn,f  Spiegler,  J  Rine- 
hart,§  Scholtz,  ||  Gassman  and  Schenkel,**  Torok  and  Schein,ft 
and  others.  The  treatment  has  proved  equally  efficacious  in 
parasitic  and  non-parasitic  sycosis.  In  some  of  the  cases  the 
patients  have  remained  well  a  year  after  the  cessation  of  treat- 
ment. A  typical  successful  case  of  parasitic  sycosis  is  that 
reported  by  Zechmeister.§§  In  this  case  the  face  was  covered 
with  deep  follicular  pustules.  Hyphomycetes  had  been  demon- 
strated around  the  roots  of  the  hairs.  After  five  strong  expos- 
ures there  was  slight  reddening  and  scaling  of  the  pustules. 
Ten  days  later  the  pustules  had  vanished,  and  in  two  weeks 
more  the  disease  had  entirely  disappeared.  Three  months  later 
the  patient  was  still  well. 

A  successful  result  in  non-parasitic  sycosis  is  shown  in  the 
following  case  treated  by  me: 

Case  15. — Man,  aged  thirty-five,  street-car  driver,  referred  to 
me  by  Dr.  Henry  F.  Lewis,  of  Chicago.  His  condition  at  the 
time  he  came  under  my  care  is  shown  in  figure  104.  The  case 
was  a  simple  sycosis  of  moderate  severity;  there  was  no  ring- 
worm fungus  present.  The  skin  was  indurated  and  boggy,  with 
gaping  hair  follicles  filled  with  pus,  and  at  one  point  there  was 
a  mass  of  exuberant  granulations,  forming  a  tumor  the  size 
of  a  mulberry.  The  disease  had  persisted  for  eight  months  in 
spite  of  vigorous  local  treatment.  After  coming  under  my 
charge  the  case  was  given  no  local  treatment  except  that  the 
patient  was  told  to  wash  off  the  surface  twice  a  day  with  soap 

*Wien.  med.  Wochens.,  1897,  xlvii,  p.  856.  Fortschr.  a.  d.  Geb.  d.  RO'nt- 
genstrahlen,  1899,  iii,  p.  109. 

fDeut.  med.  Wochens.,  1901,  xxvii,  V.  B.  p.  29. 

I  Arch.  f.  Derm.  u.  Syph.,  1901,  Ivi,  p.  131. 

I  Phila.  Med.  Jour.,  1902,  ix,  p.  221. 

||  Arch.  f.  Derm.  u.  Syph.,  1902,  lix,  p.  421. 

**  Fortschr.  a.  d.  Geb.  d.  Rontgenstrahlen,  1899,  ii,  p.  121. 

tfWien.  med.  Wochens.,  1902,  Hi,  p.  847. 

ggMonatsheft  f.  prakt.  Derm.,  1901,  xxxii,  p.  329. 


352  DISEASES    OF   THE    APPENDAGES   OF   THE    SKIN. 

and  water  and  to  protect  it  with  cloths  spread  with  boric  acid 
vaselin.  He  was  put  under  x-ray  exposures  November  4,  1901, 
but  there  was  practically  no  improvement  up  to  the  middle 
of  January.  At  that  time  a  very  slight  dermatitis  was  pro- 
duced. The  sittings  were  cautiously  continued  until  the  der- 
matitis became  rather  acute,  and  on  January  23  they  were 
discontinued.  By  February  1  there  was  complete  alopecia  over 
the  exposed  area.  After  the  appearance  of  the  erythema  there 
was  rapid  improvement  in  the  sycosis,  and  by  February  1  all 
evidence  of  disease  had  entirely  disappeared.  The  mass  of 
exuberant  granulations  referred  to  above  had  shrunken  until 
it  was  almost  on  a  level  with  the  skin,  and  was  covered  with 
healthy  epidermis.  The  condition  February  1,  1902,  is  shown 
in  figure  105.  The  beard  removed  has  since  returned,  and  the 
disease  has  not  recurred  in  ten  months,  so  that  a  cure  has 
been  produced. 

In  sycosis  the  reaction  has  to  be  carried  to  the  point  of  pro- 
ducing complete  outfall  of  the  hairs  and  enough  reaction  in  the 
skin  to  destroy  the  pus  organisms  and  mycelia  and  spores.  In 
most  of  the  cases  reported  it  has  required  the  production  of  a 
slight  dermatitis.  As  under  ordinary  circumstances  there  is 
no  reason  to  fear  that  the  hairs  removed  will  not  in  time  return, 
the  method  offers  a  distinct  advantage  over  any  other  method 
that  we  now  have  for  treating  sycosis,  whether  parasitic  or 
non-parasitic.  It  is  not  to  be  recommended  in  place  of  satis- 
factory methods  of  treatment  already  at  our  command  in  im- 
petigo or  impetiginous  eczema  of  the  bearded  part  of  the  face, 
both  of  which  are  so  frequently  confused  with  sycosis. 

Acne  Vulgaris  and  Comedo. — The  use  of  x-rays  in  acne  is 
indicated  upon  the  same  grounds  as  their  use  in  sycosis.  The 
two  qualities  of  x-rays  which  come  into  play  in  the  treatment 
of  acne,  and  of  sycosis  as  well,  are,  first,  their  property  of 
causing  atrophy  of  the  glands  of  the  skin — the  sebaceous  glands 
as  well  as  the  hair  follicles;  and,  second,  their  property  of 
destroying  bacteria  in  the  skin  and  inhibiting  the  formation 
of  pus.  Numerous  workers  have  reported  upon  the  use  of  x-rays 
in  acne.  Jutassy  *  has  noted  the  cure  of  acne  in  cases  which 

*Fortschr.  a.  d.  Geb.  d.  Riintgenstrahlen,  1900,  iii,  p.  119. 


ACNE    VULGARIS   AND    COMEDO.  355 

were  under  treatment  by  x-rays  for  other  cutaneous  troubles. 
Pakhitonov  *  has  reported  a  case  of  ten  years'  duration  which 
was  treated  successfully  by  x-rays.  Gautier  f  has  reported  fif- 
teen cases  of  acne  vulgaris  and  acne  rosacea  in  which  there  has 
been  great  improvement.  He  used  a  rather  strong  light  for 
five  or  six  minutes  daily,  at  a  distance  of  30  cm.  Good  effects 
became  apparent  after  the  sixth  sitting.  Sjogren  and  Seder- 
holm  §  have  reported  a  severe  case  almost  completely  cured 
by  x-rays,  the  pustules  and  comedones  disappearing  with  the 
passing  of  the  reaction.  Torok  and  Schein  J  have  had  three 
cases  of  acne  in  which  good  results  were  obtained  as  long  as 
they  were  under  treatment.  The  formation  of  pustules  and 
comedones  ceased  and  the  skin  became  smooth.  One  case  had 
been  free  for  three  months  at  the  time  of  the  report.  In  one 
case  under  treatment  the  upper  half  of  the  chin  became  pig- 
mented  and  the  acne  became  worse,  improving  after  six  weeks. 
Scholtz||  states  that  acne  vulgaris,  in  his  experience,  has  been 
much  improved  by  x-ray  treatment,  but  not  to  such  an  extent 
as  to  make  this  treatment  preferable  to  all  others.  The  papules 
and  comedones  disappear,  but  new  ones  sometimes  appear  even 
during  the  treatment.  Campbell**  reported  fifteen  cases  which 
were  cured  or  improved  by  x-ray  exposures  alone.  It  will 
thus  be  seen  that  the  testimony  as  to  the  benefit  of  x-ray  ex- 
posures in  acne  is  practically  unanimous.  My  own  experience 
in  acne  covers  fourteen  cases  in  which  sufficient  time  has  elapsed 
to  allow  an  estimate  as  to  the  permanency  of  the  results.  As 
briefly  as  possible  they  are  as  follows : 

Case  16. — Miss  ,  aged  twenty-two,  brunette,  was  put 

under  x-ray  exposures  in  July,  1900,  for  hypertrichosis.  On 
the  chin  and  around  the  mouth  she  had  an  acne  simplex  of 
moderate  severity.  The  lesions  were  usually  indolent  inflam- 
matory papules  without  much  induration.  Under  the  produc- 

*  Comptes  Rendus  XII  Int.  Cong,  de  Med.,  p.  382. 

fComptes  Rendus  XII  Int.  Cong,  de  Med.,  p.  385. 

{  Fortschr.  a.  d.  Geb.  d.  Rontgenstrahlen,  1901,  iv,  p.  145. 

\  Wien.  med.  "Wbchens.,  1902,  lii,  p.  847. 

||  Arch.  f.  Derm.  u.  Syph.,  1902,  lix,  p.  421. 

**  Jour.  Am.  Med.  Assoc.,  1902,  xxxix,  p.  313. 


356  DISEASES    OF   THE    APPENDAGES    OF   THE    SKIX. 

tion  of  the  first  slight  erythema  the  acne  disappeared,  and  she 
has  had  no  recurrence  in  two  years. 

Case  17. — Miss ,  aged  twenty-six.  This  case  is  identi- 
cal in  all  essential  details  with  Case  1.  The  patient  began  treat- 
ment January,  1901,  and  has  had  no  acne  since  the  production 
of  the  first  slight  erythema — two  years  ago. 

Case  18. — Miss ,  aged  twenty-six,  with  yellowish-white 

skin.  She  had  suffered  for  a  long  time  with  a  slight  acne  about 
the  chin,  with  numerous  comedones  and  constantly  recurring 
outbreaks  of  a  few  indolent  inflammatory  pustules.  She  had 
been  more  or  less  constantly  under  my  treatment  for  several 
years  for  this  acne  and  I  had  never  succeeded  in  entirely  re- 
lieving her  of  it.  Since  the  production  of  the  first  erythema, 
in  September,  1901,  she  has  had  no  acne  lesions. 

These  three  cases  have  been  under  observation  continuously. 
Cases  17  and  18  have  had  x-ray  exposures  at  intervals,  so  that 
the  effect  of  x-rays  upon  the  skin  has  been  maintained.  In  all 
the  results  are  satisfactory  from  a  cosmetic  point  of  view.  The 
skin  is  smooth  and  soft  and  of  good  color.  There  is  a  very  slight 
but  entirely  unnoticeable  atrophy  of  the  skin  in  each  of  the 
cases. 

Cose  19. — Miss  ,  aged  twenty-three,  with  brown  hair 

and  fair  skin  and  with  moderate  indurated  acne  of  the  lower 
part  of  the  face  and  forehead.  Ordinary  methods  of  treatment 
failing  after  six  weeks'  trial,  I  suggested  x-rays  in  view  of  the 
favorable  results  in  the  foregoing  cases.  She  was  given  x-ray 
exposures  with  a  very  weak  light  for  a  month  in  August  and 
September,  1901,  receiving  eighteen  exposures  in  all.  Improve- 
ment was  apparent  within  two  weeks,  and  after  a  month  there 
were  no  active  lesions  present.  At  no  time  was  an  erythema 
produced.  There  was  no  recurrence,  but  between  December 
21,  1901,  and  January  3,  1902,  she  had  ten  prophylactic  treat- 
ments without  the  production  of  erythema.  After  this,  without 
treatment,  there  occurred  an  occasional  single  small  papule, 
but  she  was  practically  free  from  the  disease  until  the  middle 
of  the  summer  of  1902.  At  that  time  there  was  a  slight  recur- 
rence, and  she  had  further  exposures  with  marked  improvement. 
The  case  has  been  improved  until  the  only  trace  of  the  disease 


ACNE   VULGARIS   AND    COMEDO.  357 

is  an  occasional  appearance  of  a  single  lesion.  Previous  to  the 
treatment  with  x-rays  there  had  been  no  time  within  twelve 
months  when  she  had  not  had  numerous  pustules  and  papules 
about  the  face. 

Case  20. — Miss  ,  aged  twenty-three,  light  brown  hair 

and  }rellowish,  pasty  skin,  was  referred  to  me  by  Dr.  Moreau 
Brown,  of  Chicago.  This  was  an  unusually  severe,  deep-seated, 
indurated  acne  of  two  years'  duration,  with  a  great  number 
of  pustules  and  many  scars.  She  was  under  x-ray  exposures 
more  or  less  regularly  from  September  16  to  December  30,  1901, 
receiving  in  all  twenty-nine  exposures.  After  December  1 
she  was  practically  free  from  acne.  The  improvement  in  this 
case  can  hardly  be  exaggerated.  The  patient  now  has  a  clean, 
healthy-looking  skin;  there  are,  of  course,  numerous  scars  left, 
but  no  other  traces  of  acne. 

Case  21. — Miss ,  aged  twenty-two.  This  was  an  acne 

simplex  of  moderate  severity  under  the  chin  and  about  the 
face  in  a  young  woman  with  a  sluggish  skin.  It  was  greatly 
improved  under  x-ray  exposures  between  December  14,  1901, 
and  February  27,  1902.  Without  further  treatment  she  re- 
mained well  for  several  months,  but  in  October,  1902,  she 
returned  with  some  recurrence. 

Case  22. — Miss ,  aged  sixteen,  with  black  hair  and  fair 

skin.  This  was  a  typical  extremely  severe  juvenile  acne  with 
a  great  number  of  comedones  and  superficial  pustules.  The 
disease  had  existed  for  two  years  practically  unchanged  in 
spite  of  constant  treatment.  Between  January  2  and  March 
31,  1901,  she  had  fifty-three  exposures,  with  the  entire  dis- 
appearance of  the  acne  and  practically  entire  disappearance  of 
comedones.  The  improvement  in  this  case  is  remarkable  and 
is  such  as  I  have  never  seen  from  any  other  treatment  of  a 
similar  case.  She  is  free  from  acne  and  comedones  and  the 
skin  is  of  good  color.  Eight  months  later  she  remains  well. 

Case  23. — Mrs.  ,  aged  thirty-five,  with  dark  hair  and 

fair  skin,  spare  built,  anemic,  with  constantly  appearing  papules 
about  the  face  and  chin  and  a  few  comedones.  This  patient 
has  been  under  my  care  at  times  from  January  2,  1902,  to  date. 
Under  the  first  series  of  x-ray  exposures  the  acne  was  greatly 


358  DISEASES    OF   THE    APPENDAGES    OF   THE    SKIN. 

improved.  From  February  to  May,  1902,  she  had  no  exposures. 
There  was  a  recurrence  of  a  few  acne  lesions  in  the  mean  time. 
During  the  past  summer  [1902]  she  had  fifteen  exposures  in 
two  months  with  decided  improvement  in  her  condition.  She 
still  has,  however,  at  times,  outbreaks  of  a  few  acne  lesions. 

Case  24. — Miss  ,  aged  twenty-four,  with  dark  hair 

and  fair  skin.  For  five  years  she  had  had  a  very  severe,  indo- 
lent, deep-seated  acne.  The  skin  was  pale  and  sluggish  and 
the  cheeks  were  covered  with  dark  red,  deep-seated,  indolent 
lesions,  which  would  remain  for  weeks  without  the  formation 
of  a  well-developed  pustule.  Between  January  2  and  March 
31,  1902,  she  had  forty-five  exposures  with  complete  disap- 
pearance of  the  acne.  The  improvement  in  this  condition 
could  hardly  have  been  greater.  I  believe  she  remains  well 
now,  eight  months  after  stopping  treatment. 

Case  25. — Miss ,  aged  eighteen,  referred  to  me  by  Dr. 

D.  A.  K.  Steele,  of  Chicago;  a  healthy,  vigorous  young  woman 
with  a  moderate  but  very  persistent  juvenile  acne.  There  were 
not  many  comedones  but  there  were  constantly  recurring 
groups  of  indurated  papules  without  much  elevation  and  very 
slow  to  disappear.  The  patient  has  been  under  the  care  of 
many  excellent  dermatologists  without  at  any  time  disappear- 
ance of  the  disease.  She  has  had  exposures  to  x-rays  for  several 
periods  between  January  and  October,  1902.  Her  acne  has  at 
times  entirely  disappeared  and  remained  well  for  several  months, 
but  she  has  occasionally  one  or  two  lesions.  The  improvement, 
however,  is  very  great. 

Case  26. — Mrs.  ,  aged  forty,  with  black  hair  and  a 

florid  complexion  and  with  a  severe  persistent  acne  around  the 
mouth  and  cheeks.  Between  January  2  and  March  28,  1902, 
this  patient  had  thirty-eight  exposures.  There  was  little  im- 
provement during  the  first  two  months  in  spite  of  the  fact 
that  reaction  was  carried  to  the  production  of  slight  pigmenta- 
tion. At  the  end  of  the  treatment  there  was  rather  an  acute 
reaction  produced  which  showed  especially  in  an  increase  of 
the  folliculitis.  After  two  weeks  this  disappeared,  and  with 
it  the  acne.  Since  April,  1902,  there  has  been  a  very  great 


ACNE    VULGARIS   AND    COMEDO.  359 

improvement  in  the  condition  of  her  complexion.  She  still  has 
occasionally  an  inflamed  follicle,  but  is  practically  well. 

Case  27. — Miss  ,  aged  fourteen,  with  severe  juvenile 

acne.  This  case  is  practically  a  duplicate  of  Case  22.  Under 
x-ray  exposures  given  between  January  and  June,  1902, — fifty- 
six  in  all, — the  disease  has  practically  disappeared.  Since  June, 
1902,  she  has  had  no  treatment  and  there  has  been  almost  no 
recurrence. 

Case  28. — Mrs. ,  aged  thirty-three,  with  dark  hair  and 

fair  skin,  with  a  severe  indurated  acne.  The  course  of  this  case 
was  very  closely  similar  to  that  of  Case  26.  The  lesions  were 
intractable  at  the  start  and  the  exposures  were  carried  to  the 
point  of  producing  an  acute  folliculitis,  upon  the  subsidence 
of  whch  the  acne  disappeared,  and  from  February  25  to  October 
1,  1902,  the  patient  remained  well.  In  October,  1902,  she  had 
a  relapse. 

The  marked  increase  in  the  folliculitis  without  the  develop- 
ment of  much  erythema  in  the  surrounding  skin  was  a  curious 
fact  noted  in  both  Cases  26  and  28.  A  similar  exaggeration 
of  the  acne  before  improvement  is  noted  in  a  case  of  Torok 
and  Schein  referred  to  above. 

Case  29. — Mrs.  ,  aged  thirty-five,  very  dark  hair  and 

fair  skin,  with  a  moderate  indurated  acne.  In  this  case  the 
acne  was  cleaned  up  with  scattered  exposures  during  February 
and  March,  1902,  and  she  has  remained  practically  well  since 
that  date. 

The  physical  condition  in  all  of  these  patients  was  about 
such  as  one  usually  sees  in  acne ;  digestive  disturbances,  usually 
constipation  in  some  of  them,  and  some  of  them  anemic.  Most 
of  the  patients  were  in  average  health.  The  only  one  that 
showed  a  marked  departure  from  health  was  Case  24.  This 
young  woman  had  had  a  chronic  diarrhea  for  several  years 
and  was  very  anemic;  at  the  beginning  of  treatment  she  had 
50  per  cent,  hemoglobin.  She  had  internal  treatment  along  the 
usual  lines  for  such  conditions  while  having  x-ray  exposures, 
with  considerable  improvement  in  her  general  health.  When 
there  was  anemia  or  other  indication  to  be  met,  the  patients 
had  treatment  along  the  usual  lines.  Of  local  treatment  they 


360  DISEASES    OF   THE    APPENDAGES    OF   THE    SKIN. 

had  very  little,  for  the  reason  that  it  is  undesirable  to  run  the 
risk  of  confusing  an  irritation  of  the  skin  such  as  is  caused  by 
the  applications  used  in  acne  with  an  x-ray  dermatitis.  In 
accounting  for  the  results  I  believe  the  effect  of  the  local  treat- 
ment other  than  x-rays  and  of  internal  treatment  are  entitled 
to  very  little  weight.  Almost  all  of  the  cases  had  failed  of 
relief  under  the  usual  methods  of  treatment  and  the  effect  of 
x-ray  exposures  was  direct  and  prompt,  leaving  no  uncertainty 
as  to  the  part  they  played  in  the  improvement. 

I  think  it  may  be  safely  said  that  in  x-rays  we  have  found 
a  method  of  treating  acne  more  effective  than  any  hitherto 
at  our  command  in  the  treatment  of  that  most  intractable 
affection.  As  to  the  permanency  of  the  results,  some  of  my 
cases  have  shown  no  recurrence  in  a  year  without  treatment. 
In  others  there  has  been  some  relapse,  but  the  relapses  have 
been  slight  and  have  proved  tractable  to  further  treatment. 
And  even  if  it  is  found  that  the  relapses  occur  at  times,  it  lessens 
very  little  the  value  of  the  method,  for  it  still  gives  a  satis- 
factory means  of  controlling  this  usually  self-limiting  disease. 
My  experience  shows  that  the  results  are  decidedly  persistent, 
and  that  we  may  reasonably  hope  entirely  to  cure  an  acne 
by  a  little  treatment  with  x-rays  from  time  to  time,  after  the 
disease  has  once  been  relieved. 

It  has  been  suggested  that  possibly  the  skin  might  be  damaged 
by  the  atrophy  of  the  follicles  produced  in  treating  acne  by 
this  method.  Unquestionably  if  it  were  necessary  to  carry  the 
process  to  the  point  of  causing  destruction  of  the  follicles,  as 
in  treating  hypertrichosis,  for  example,  this  question  would  have 
to  come  into  consideration.  Further,  if  the  treatment  had  to 
be  carried  to  such  a  point  it  would  lose  much  of  its  value  because 
of  the  great  difficulty,  which  is  seen  in  treating  hypertrichosis, 
of  carrying  the  reaction  to  the  point  of  causing  destruction 
of  follicles  without  damaging  the  skin.  But  in  treating  acne  it 
is  not  necessary  to  carry  the  reaction  to  the  point  of  causing 
more  than  the  slightest  atrophy  of  the  follicles.  To  produce 
the  effect  desired  it  is  only  necessary  to  cause  a  slight  reaction, 
a  reaction  sufficient  to  lessen  somewhat  the  functional  activity 
of  the  glands  but  not  sufficient  to  cause  their  complete  atrophy. 


ROSACEA.  361 

With  the  slight  reaction  necessary  in  order  to  relieve  an  acne 
it  is  altogether  to  be  expected  that  in  time  complete  regeneration 
of  the  glands  will  occur. 

Of  course,  in  treating  cosmetic  difficulties  like  acne  the  greatest 
caution  must  be  used  to  avoid  untoward  effects.  In  my  cases 
I  have  constantly  used  a  very  weak  light.  A  light  that  is  just 
strong  enough  to  show  as  a  green  glow  in  the  tube  has,  in  my 
experience,  proved  sufficient.  With  such  a  light  exposures  of 
five  to  ten  minutes'  duration  are  given  with  the  tube  at  a  dis- 
tance of  10  to  15  cm.,  and  these  are  repeated  daily  or  every 
second  day,  or  at  times  even  less  frequently.  I  have  found  no 
condition  in  which  improvement  under  z-rays  occurs  more 
promptly  than  in  acne.  Many  of  the  cases  have  gotten  well 
without  the  production  of  anything  more  than  a  very  slight 
pigmentation  or  the  slightest  erythema.  In  only  two  cases  has 
there  been  produced  a  reaction  of  more  than  the  slightest 
intensity. 

Rosacea. — X-rays  have  also  been  used  in  the  treatment  of 
acne  rosacea.  Gautier  *  has  reported  good  results  in  rosacea. 
Hahn  f  has  reported  two  cases  in  which  he  obtained  excellent 
results;  in  these  cases  there  was  no  return  in  two  years. 
Scholtz  |  also  reports  improvement  in  rosacea,  but  not  to  an 
extent  to  make  the  treatment  preferable  to  other  methods. 

I  have  used  the  method  in  one  case: 

Case  30. — Miss ,  aged  twenty-nine,  with  a  very  severe 

rosacea  accompanied  by  a  folliculitis  involving  the  entire  flush 
area  of  the  face.  The  nose  was  very  red  with  slight  hyper- 
trophy, and  there  were  numerous  large  indurated  pustules  on 
the  nose  and  cheeks,  around  the  mouth,  and  on  the  forehead. 
The  disease  had  persisted  for  six  years  in  spite  of  treatment. 
Patient  suffered  from  chronic  constipation,  but  was  otherwise 
well.  This  patient  had  treatment  during  December,  1901,  and 
January  and  February,  1902,  having  mild  exposures  about 
every  other  day.  After  a  month  there  was  considerable  im- 
provement in  the  condition,  and  after  the  fifth  of  March  the 

*Comptes  rendus  XII  Int.  Cong,  de  M6d.,  p.  385. 

t  Fortschr.  a.  d.  Geb.  d.  Rontgenstrahlen,  1901,  iv,  p.  95. 

J  Arch.  f.  Derm.  u.  Syph.,  1902,  lix,  p.  421. 


362  DISEASES    OF   THE    APPENDAGES    OF   THE    SKIN. 

folliculitis  had  disappeared.  Since  that  time  she  has  had  inter- 
mittent treatment  without  at  any  time  recurrence  of  acne. 
At  no  time  has  there  been  a  perceptible  x-ray  effect  on  the 
skin. 

There  is  a  slight  rosacea  left  on  the  tip  of  the  nose,  but  other- 
wise the  disease  has  disappeared.  The  folliculitis,  which  was 
such  a  marked  feature  of  the  disease,  has  shown  no  tendency 
to  reappear  in  eight  months,  and  there  are  only  a  few  thin 
telangiectases.  The  skin  is  smooth,  clean,  of  normal  color,  and 
altogether  the  improvement  is  remarkably  great.  I  have  cer- 
tainly never  seen  such  an  improvement  in  any  other  case  of 
rosacea  of  equal  severity. 

It  would  seem  that  the  method  offers  a  valuable  addition  to 
our  means  of  treating  the  folliculitis  which  accompanies  rosacea, 
and  which  with  the  perifollicular  inflammation  plays  so  im- 
portant a  role  in  the  disfigurement  caused  by  that  disease. 
That  x-rays  will  affect  the  telangiectases  found  in  rosacea  there 
is  good  reason  to  doubt,  and  it  is  probable  that  in  order  to 
get  the  best  results  the  use  of  electrolysis  or  some  other  method 
to  destroy  the  dilated  blood-vessels  will  be  a  necessary  addition 
to  this  method  of  treatment. 

Hyperidrosis. — The  effect  of  x-rays  is  perhaps  less  upon  the 
sweat-glands  than  upon  either  the  hair  follicles  or  the  sebaceous 
glands.  Histological  studies,  however,  indicate  that  there  is 
some  atrophy  of  the  sweat-glands  as  a  result  of  x-ray  exposures, 
and  there  seems,  therefore,  some  theoretical  ground  for  believing 
that  the  use  of  x-rays  may  be  beneficial  in  local  forms  of  hyper- 
idrosis.  So  far  as  I  know,  no  one  has  attempted  to  use  x-ray? 
for  this  purpose,  and  I  have  not  tried  the  experiment  myself, 
but  I  believe  there  is  sufficient  ground  to  warrant  its  trial  in 
intractable  cases  of  local  hyperidrosis,  as,  for  instance,  of  the 
axilla  or  of  the  feet. 


CHAPTER  IX. 
INFLAMMATORY  DISEASES  OF  THE  SKIN. 

X-RAYS  have  been  used  in  the  treatment  of  a  number  of 
diseases  of  the  skin,  such  as  eczemas,  psoriasis,  lichen  planus, 
and  lupus  erythematosus,  in  which  the  skin  is  thickened  and 
indurated  as  a  result  of  a  chronic  inflammatory  process  and 
in  which  there  is  need  of  "stimulation  of  the  tissues  in  order 
to  get  rid  of  the  inflammatory  exudate. " 

Eczema. — Several  writers  have  reported  their  results  in  the 
treatment  of  eczema.  Ullman  *  recommends  the  use  of  x-rays 
in  eczema,  especially  of  the  chronic  indurated  type.  Jutassy  f 
has  reported  an  intractable  eczema  of  the  hands,  cured  by 
x-ray  exposures,  with  no  return  in  two  years.  Schiff  and 
Freund  J  have  reported  a  case  of  chronic  eczema  of  the  beard 
cured  in  eleven  exposures.  Williams  §  has  reported  two  cases. 
The  first  case  was  that  of  a  man  fifty  years  old,  who  had 
attacks  of  eczema  every  winter,  requiring  treatment  by  the 
ordinary  methods  for  some  months  before  relief  was  obtained. 
When  applying  for  treatment,  there  was  a  red  area  on  the 
outer  part  of  the  left  arm,  15  cm.  by  10  cm.,  rough  but  not 
moist,  which  itched  intensely.  A  single  exposure  was  given  for 
ten  minutes  at  10  cm.  distance,  and  on  the  following  morning 
there  was  no  itching  and  no  discomfort  over  the  part  treated 
by  the  x-rays,  and  the  patient  had  no  further  trouble.  The 
second  case  was  a  chronic  eczema  of  the  back,  neck,  and  arms, 
with  much  itching.  Daily  exposures  for  many  days  afforded 
the  patient  no  relief. 

Hahn  ||  has  treated,  with  excellent  results,  thirty-five  cases 

*Wien.  med.  Presse,  1900,  xli,  p.  954. 
tFortschr.  a.  d.  Geb.  d.  Rontgenstrahlen,  1900,  iii,  p.  119. 
J  Fortschr.  a.  d.  Geb.  d.  Rontgenstrahlen,  1900,  iii,  p.  109. 
\  "The  Rontgen  Rays  in  Medicine  and  Surgery,"  p.  409. 
||  Fortschr.  a.  d.  Geb.  d.  Rontgenstrahlen,  1901,  v,  p.  39. 
363 


364  INFLAMMATORY    DISEASES    OF   THE    SKIN. 

of  eczema.  He  reports  that  improvement  has  been  so  rapid 
in  some  cases  that  in  one  day  an  eczematous  surface  has  become 
normal.  Itching  has  always  ceased  after  a  few  exposures. 
The  disease  in  some  of  his  cases  recurred,  but  disappeared 
on  renewal  of  treatment.  He  has  not  found  it  necessary  to 
produce  any  apparent  reaction. 

Sjogren  and  Sederholm  *  have  reported  ten  cases  of  chronic 
eczema,  in  the  majority  of  which  a  cure  was  effected.  Itching 
was  relieved  in  all  cases.  Some  of  them  showed  recurrence. 
One  case  proved  refractory,  and  had  no  lasting  benefit. 

Albers-Schonberg  f  has  described  three  cases  of  chronic 
eczema,  which  under  x-rays  showed  an  unusually  rapid  healing. 

Harm  and  Albers-Schonberg  J  have  together  reported  four- 
teen cases,  with  results  similar  to  those  in  the  cases  reported 
by  them  separately. 

Mackey  §  has  reported  two  cases  of  chronic  eczema  which 
had  for  a  time  been  treated  unsuccessfully  by  ordinary  methods, 
and  which  were  greatly  improved  under  short  periods  of  treat- 
ment with  x-rays. 

Meek  ||  has  reported  three  cases  of  eczema;  one  acute,  with 
relief  in  two  treatments;  twro  chronic,  one  relieved  in  nineteen 
treatments,  another  in  eighteen  treatments. 

Scholtz**  concludes  from  his  experience  that  eczema  is  influ- 
enced hi  a  most  satisfactory  manner  by  x-ray  exposures.  All 
of  his  patients  stated  after  a  few  exposures  that  itching  had 
ceased,  and  in  three  obstinate  and  often  recurring  cases  the 
improvement  was  remarkable.  The  moisture  and  redness  dis- 
appeared and  the  scaling  was  lessened.  He  recommends  the 
use  of  x-rays  especially  as  auxiliary  to  other  methods  of  treat- 
ment in  eczema. 

It  will  be  seen  that  there  is  a  good  deal  of  evidence  of  the 
value  of  x-rays  in  both  acute  and  chronic  forms  of  eczema.  There 
is  general  testimony  as  to  the  relief  of  the  itching,  in  both  acute 

*Fortschr.  a.  d.  Geb.  d.  Routgenstrahlen,  1901,  iv,  p.  145. 
f  Fortschr.  a.  d.  Geb.  d.  Rcintgenstrahlen,  1898,  ii,  p.  20. 
+  Munch,  med.  Wochens.,  1900,  xlvii,  pp.  284,  324,  363. 
I  Brit.  Jour.  Dermatology,  1899,  xi,  p.  160. 
||  Boston  Med.  and  Surg.  Jour.'.  1902,  cxlvii,  p.  152. 
**Arch.  f.  Derm.  u.  Syph.,  1902,  lix,  p.  421. 


PSORIASIS.  365 

and  chronic  forms.  The  use  of  x-rays  in  acute  types  of  eczema 
will  probably  have  a  much  more  limited  application  than  in  the 
chronic  indurated  forms  of  that  disease.  It  is  not  easy  to  find  a 
reason  for  expecting  x-rays  to  be  of  marked  value  in  acute  vesic- 
ular or  papular  eczema,  beyond  the  effect  which  they  would  have 
upon  the  itching,  unless  they  have  some  peculiar  influence  upon 
the  metabolism  and  structure  of  the  diseased  cells,  of  the  char- 
acter of  which  we  know  nothing.  There  are  good  a  priori  grounds 
for  expecting  benefit  in  chronic  indurated  patches  of  eczema 
in  which  there  is  need  for  marked  stimulation  in  order  to  get 
absorption  of  inflammatory  products.  It  seems  probable  that 
the  chief  use  of  x-rays  in  eczema  will  be  in  the  treatment  of 
the  intractable  circumscribed  indurated  patches  of  chronic 
eczema.  That  they  have  a  valuable  field  of  usefulness  in  these 
cases  there  seems  little  room  to  doubt. 

Psoriasis. — The  use  of  x-rays  in  the  treatment  of  psoriasis 
has  been  reported  in  numerous  quarters. 

Strater  *  has  reported  the  relief  of  an  area  of  psoriasis 
exposed  to  the  rays  from  a  soft  tube,  while  a  second  area  ex- 
posed to  the  rays  from  a  hard  tube  was  unaffected. 

Startin  f  has  reported  a  case  of  psoriasis  of  the  legs,  arms, 
and  body,  which  was  relieved  by  usual  methods  of  treatment, 
except  for  one  obstinate  patch  three  by  six  inches  in  size  on 
the  inside  of  the  leg.  This  was  exposed  to  x-rays  seven  times, 
exposure  being  given  every  three  days,  with  the  result  that 
in  two  weeks  after  the  last  exposure  the  whole  patch  vanished, 
leaving  healthy  skin. 

Hahn  J  states  that  six  cases  of  psoriasis  treated  by  x-ray 
exposures  were  greatly  benefited.  In  his  cases,  after  four  to 
six  exposures,  the  scales  fell  off  with  no  bleeding.  In  two 
cases  some  excoriation  appeared  on  the  exposed  areas,  disap- 
pearing in  two  weeks.  Recurrences  took  place  in  all  cases. 

Sjogren  and  Sederholm  §  in  two  cases  have  found  the  use 
of  x-rays  of  but  slight  value.  In  these  cases  there  was  slight 
improvement,  which  proved  temporary. 

*Deutsch.  med.  Wochens.,  1900,  xxvi,  p.  546.  |  Lancet,  1901,  ii,  p.  144. 

J  Fortschr.  a.  d.  Geb.  d.  Routgenstrahlen,  1901,  v,  p.  39. 
\  Fortschr.  a.  d.  Geb.  d.  Rontgenstrableu,  1901,  iv,  p.  145. 


366  INFLAMMATORY    DISEASES   OF   THE    SKIN. 

Williams*  has  reported  one  case:  "A.  B.  Psoriasis  of  forty 
years'  duration.  When  this  patient  came  to  me  for  treatment 
by  the  x-rays,  nearly  the  whole  of  the  front,  back,  and  sides 
of  the  body  were  affected.  Five  exposures  of  twenty  minutes 
each  caused  marked  improvement  in  the  area  treated;  the  skin 
became  soft  and  smooth,  although  still  remaining  of  a  reddish 
color  for  a  few  days." 

Scholtz  t  states  that  in  the  treatment  of  psoriasis  there  is 
great  improvement  under  x  -rays.  In  most  patients  almost 
complete  healing  has  resulted;  in  some  absolute  cure.  Where 
the  disease  is  not  entirely  removed,  the  subsequent  application 
of  chrysarobin  quickly  completes  the  cure.  After  three  or  four 
exposures  of  fifteen  to  twenty  minutes,  at  40  cm.  distance, 
the  intense  red  color  is  lessened  and  a  yellowish-brown  pig- 
mentation begins  on  the  edges  of  the  affected  areas.  The  scales 
form  less  rapidly  and  may  be  detached  without  the  appearance 
of  the  characteristic  bleeding  points.  Later  the  pigmentation 
spreads  and  becomes  more  intense  and  of  a  copper  brown  color. 
Finally  the  scales  fall  off  and  the  skin  appears  smooth  with 
merely  slight  roughness  and  pigmentation  both  over  the  dis- 
eased area  and  over  the  normal  skin.  These  changes  have 
taken  place  in  several  of  his  cases. 

I  have  treated  patches  of  psoriasis  on  the  forearms  in  a 
patient  with  a  very  severe  intractable  psoriasis  of  many  years' 
duration. 

Case  31. — In  this  case,  without  at  any  time  getting  up  a 
reaction,  it  has  been  possible  to  improve  the  condition  very 
much.  The  scales  fall  off,  the  redness  becomes  markedly  less, 
and  the  skin  almost  smooth,  but  the  disease  has  shown  a  ten- 
dency to  recur. 

There  is  no  doubt  that  patches  of  psoriasis  can  be  cleared 
up  by  exposure  to  x-rays.  There  is  no  reason  to  believe,  how- 
ever, that  such  treatment  will  overcome  the  marked  tendency 
of  the  disease  to  recur,  and,  as  experience  already  shows, 
relapses  will  probably  usually  occur.  The  method,  however, 
has  the  advantage  of  being  free  from  the  use  of  the  unsightly 

*  "  The  Rontgen  Rays  in  Medicine  and  Surgery,"  p.  653. 
t  Arch.  f.  Derm.  u.  Syph.,  1902,  lix,  p.  421. 


LICHEN    PLANUS.  367 

and  disagreeable  local  applications  used  ordinarily  in  treating 
psoriasis  and  is  easy  of  application.  In  addition,  it  is  effective 
in  certain  intractable  cases  in  which  the  ordinary  remedies 
have  failed. 

In  carrying  out  the  treatment  in  psoriasis,  where  the  disease 
is  at  all  extensive,  it  is  desirable,  as  Hahn  suggests,  to  place 
the  tube  at  some  distance  from  the  surface,  in  order  that  an 
almost  equal  effect  of  the  rays  may  be  produced  at  one  time 
over  a  large  surface. 

Lichen  Planus. — Scholtz  *  has  reported  the  only  case  in  the 
literature  of  lichen  planus  treated  by  x-rays — a  patient  with 
universal  lichen  planus  in  which  the  eruption  on  the  right 
leg  disappeared  after  a  few  exposures  with  slight  scaling  and 
pigmentation.  At  the  same  time  there  was  noticeable  increase 
in  other  parts  of  the  eruption  which  were  unexposed.  Scholtz 
concludes  that  in  lichen  planus  cure  by  x-rays  is  not  so  quick 
as  by  other  means,  but  a  trial  of  the  method  is  strongly  to  be 
advised  in  obstinate  cases. 

Case  32. — I  have  treated  by  x-rays  one  case  of  lichen  planus 
of  the  scrotum.  This  patient,  a  man  twenty-nine  years  old, 
in  good  health,  had  an  indurated,  sharply  defined,  irregular 
patch  of  lichen  planus  on  the  scrotum  2^  by  4  inches  in  size. 
There  were  also  two  or  three  other  small  patches  one-half  inch 
in  diameter.  The  disease  appeared  three  years  after  a  severe 
nervous  strain  and  had  at  no  time  shown  any  tendency  to 
get  well.  There  was  no  lichen  planus  elsewhere  on  the  patient's 
body,  but  from  the  purplish  color  of  the  patches,  the  slight 
branny  desquamation,  the  sharp  border,  the  induration,  the 
itching,  and  the  character  of  the  peripheral  lesions,  I  have  no 
doubt  as  to  the  diagnosis.  This  patient  had  thirty-one  weak 
exposures  between  May  15  and  July  18,  1902.  The  first  effect 
was  a  relief  of  the  itching,  and  soon  the  patches  began  to  fade 
out.  Since  June  15,  1902,  all  trace  of  the  disease  has  disap- 
peared and  the  skin  has  been  normal.  There  was  no  visible 
reaction  produced  in  getting  this  improvement.  With  the 
exception  of  a  group  of  lesions  \  inch  in  diameter  which  appeared 
in  July  and  quickly  disappeared  under  x-ray  exposures,  there 

*Arch.  f.  Derm.  u.  Syph.,  1902,  lix,  p.  421. 


368  INFLAMMATORY    DISEASES    OF   THE    SKIN. 

has  been  no  evidence  of  the  disease  since  June,  1902.  It  is 
hard  to  imagine  the  fading  of  a  chronic  inflammatory  process 
in  the  skin  in  a  way  more  striking  than  occurred  in  this  case. 

Lupus  Erythematosus. — In  consequence  of  the  good  effect  of 
x-rays  in  lupus  vulgaris  their  use  was  tried  in  lupus  erythe- 
matosus  early  in  the  history  of  radiotherapy,  and  numerous 
reports  upon  the  treatment  of  this  disease  by  x-rays  are  found 
in  the  literature. 

Beck  *  has  reported  one  case  of  lupus  erythematosus  cured 
under  x-ray  exposures,  and  Lee  f  has  reported  one  in  which 
there  was  great  improvement. 

Sjogren  J  has  treated  six  cases  of  lupus  erythematosus,  of 
which  five  have  been  cured.  All,  however,  required  repeated 
periods  of  treatment  on  account  of  recurrences,  which  were 
probably  due,  in  his  opinion,  to  some  areas  not  having  been 
properly  submitted  to  the  rays.  He  found  that  treatment  must 
be  carried  to  the  point  of  severe  reaction.  A  clear  atrophic 
skin  is  seen  after  a  cure  of  the  patches,  similar  to  very  thin 
scar  tissue. 

Startin  §  has  reported  the  case  of  a  young  married  woman 
with  a  well-marked  butterfly  patch  of  lupus  erythematosus, 
bright  red  in  color  and  acutely  inflamed.  Other  treatment 
having  proved  ineffective,  the  case  was  given  x-ray  exposures 
every  three  days  until  six  treatments  had  been  given,  the 
result  being  the  formation  of  a  healthy  looking  cicatrix. 

Jutassy  ||  has  reported  the  cure  of  a  case  which  remained 
well  eighteen  months,  when  there  was  a  slight  recurrence. 

Schiff  and  Freund  **  have  reported  the  cure  of  a  case  of 
lupus  erythematosus  of  the  side  of  the  face,  in  which  there 
was  the  unintentional  production  of  an  alopecia  that  proved 
permanent.  This  the}-  very  reasonably  attribute  to  the  effect 
of  the  disease  rather  than  to  the  x-rays.  In  another  case  of 
Schiff 'sff  a  patch  of  lupus  erythematosus  on  one  side  of  the 

*  Medical  Record,  1902,  Ixi,  p.  33. 

f  Brooklyn  Med.  Jour.,  1902,  xvi,  p.  85. 

J  Fortschr.  a.  d.  Geb.  d.  Rontgenstrahlen,  1901,  v,  p.  37. 

^  Lancet,  1901,  ii,  p.  144. 

HFortschr.  a.  d.  Geb.  d.   Rontgenstrahlen,  1900,  iii,  p.  119. 

**  Festschrift  Neumann,  p.  805.  ft  "NVieu.  med.  Presse,  1899,  xl,  p.  57. 


LUPUS    ERYTHEMATOSUS.  369 

face  was  cured  by  x-rays,  while  the  condition  of  the  patch  on 
the  other  side,  which  was  not  exposed,  was  not  affected.  The 
skin  after  the  disappearance  of  the  disease  was  entirely  smooth, 
and  even  almost  normal  in  appearance. 

Torok  and  Schein*  have  reported  two  cases  with  improve- 
ment. Scholtz  f  states  that  in  lupus  erythematosus  he  has 
obtained  by  severe  exposures  followed  by  superficial  necrosis 
results  very  satisfactory  from  a  cosmetic  point  of  view,  but 
in  the  course  of  a  few  months  relapses  have  occurred.  In  other 
cases  apparently  complete  cure  has  resulted  from  slight  expo- 
sures continued  for  months.  Sjogren  and  Sederholm  J  and 
Grouven  §  are  of  similar  opinions. 

On  the  other  side,  Hall-Edwards  ||  has  reported  a  case  of 
lupus  erythematosus  of  the  face  and  arm  in  a  girl  eighteen 
years  old,  in  which  the  patch  on  the  arm  was  given  one  exposure 
at  one  inch,  and  a  second  nine  days  later.  An  x-ray  slough 
resulted  with  an  ulceration  which  healed  in  two  months.  The 
unexposed  disease  on  the  face  disappeared  sooner. 

Case  33. — I  have  had  under  treatment  for  four  months  one 
case  of  lupus  erythematosus — a  typical  saddle-shaped  patch  on 
the  nose  and  cheeks,  in  a  woman  thirty  years  old.  The  disease 
has  existed  for  eight  years  and  has  had  previous  x-ray  exposures 
which  were  carried  to  the  point  of  producing  an  acute  derma- 
titis without  effect  on  the  disease.  Under  x-ray  exposures 
which  have  not  been  sufficiently  intense  to  cause  an  acute 
reaction  there  has  been  very  marked  improvement  in  the 
disease.  It  has  gotten  better  than  it  has  been  in  many  years 
before.  The  skin  is  smooth,  without  elevation  or  scaling,  but 
there  is  still  some  induration  at  certain  points  of  the  border, 
so  that  the  disease  is  not  yet  cured. 

With  a  disease  so  capricious  in  its  course  as  lupus  erythema- 
tosus one  must  be  extremely  careful  in  drawing  any  conclusions 
as  to  the  efficacy  of  any  method  of  treatment,  and  it  is  impossible 
with  our  short  experience  with  x-rays  in  this  disease  to  form 

*Wien.  mecl.  "Wochens.,  1902,  Hi,  p.  847. 
fArch.  f.  Dorm.  u.  Syph.,  1902,  lix,  p.  421. 
JFortschr.  a.  d.  Geb.  d.  Rontgenstrahlen,  1901,  iv,  p.  145 
\  Deut.  med.  \Voohens.,  1901,  xxvii,  V.  B.,  p.  119. 
||  Edinburgh  Med.  Jour..  1900,  xlix,  p.  i:«). 
24 


370  INFLAMMATORY    DISEASES   OF  THE    SKIN. 

a  definite  opinion  as  to  their  value.  It  seems  probable,  how- 
ever, from  our  present  experience  that  x-rays  will  prove  an 
addition  to  the  measures  at  our  command  in  the  treatment  of 
lupus  erythematosus.  Certainly  the  reports  which  we  have 
show  better  and  more  constant  results  than  are  gotten  by  any 
other  method  of  treating  this  extremely  capricious  disease. 
It  is  probable  that  some  cases  will  not  be  affected  by  them, 
and  surely  relapses  in  a  certain  proportion  of  the  cases  must 
be  expected.  But  even  granting  this,  there  is  still  a  chance 
of  the  method  proving  an  advance  in  treatment.  Bearing  in 
mind  other  methods  of  treating  lupus  erythematosus  and  our 
experience  in  the  treatment  with  x-rays  of  other  chronic  in- 
flammatory processes  in  the  skin,  it  seems  probable  that  the 
method  of  using  x-rays  in  the  treatment  of  lupus  erythematosus 
that  will  be  most  efficient  is  the  use  of  exposures  of  weak  inten- 
sity, which  may  be  kept  below  the  point  of  causing  an  acute 
reaction.  In  my  opinion  these  mild  exposures  should  be  tried 
first,  and  intense  exposures  resorted  to  only  when  the  weaker 
ones  have  persistently  failed. 

Prurigo  and  Urticaria  Pigmentosa. — It  is  interesting  to  note, 
in  connection  with  the  consideration  of  the  foregoing  diseases, 
reports  upon  the  treatment  with  x-rays  of  prurigo  and  urticaria 
pigmentosa. 

Hahn  *  reports  the  cure  of  a  case  of  prurigo,  without  the  induc- 
tion of  any  reaction.  The  formation  of  nodules  and  the  itching 
ceased  altogether  except  in  those  places  not  directly  reached 
by  the  x-rays.  On  the  other  hand,  Scholtz  f  reports  that  in 
a  case  of  prurigo  treated  by  x-ray  exposures,  no  effect  was  seen. 

Torok  and  Schein  J  have  reported  the  successful  treatment 
of  urticaria  pigmentosa  which  was  exposed  to  x-rays  with  the 
production  of  an  acute  dermatitis.  With  the  subsidence  of 
this  reaction  the  skin  over  the  whole  area  became  darkly  pig- 
mented  and  the  urticarial  markings  disappeared,  and  could  not 
be  made  to  reappear  by  mechanical  irritation.  The  pigmenta- 
tion finally  almost  entirely  disappeared. 

*Fortschr.  a.  d.  Geb.  d.  Rontgenstrahlen,  1901,  v,  p.  39. 
f  Archiv  f.  Derm.  u.  Syph.,  1902,  lix,  p.  421. 
JWien.  med.  Wochens.,  1902,  lii,  p.  847. 


CHAPTER  X. 
TREATMENT  OF  TUBERCULOSIS  BY  X-RAYS, 

Lupus  Vulgaris. — The  treatment  of  lupus  vulgaris  by  exposure 
to  x-rays  was  the  first  use  of  that  agent  that  was  made  in  the 
treatment  of  cutaneous  disease.  It  had  previously  been  used 
by  Freund  in  the  removal  of  hair,  but  its  first  application  to 
diseased  tissues  was  in  lupus  vulgaris,  and  the  first  intimation 
that  we  had  of  its  brilliant  therapeutic  possibilities  was  shown 
in  its  effect  in  removing  the  lesions  of  lupus.  It  is  an  interesting 
fact  that  the  first  successful  use  of  radiotherapy  was  in  the 
same  disease  in  which  Finsen  had  had  such  notable  success  by 
the  use  of  phototherapy,  and  it  may  be  that  among  the  debts 
that  we  owe  to  Finsen  is  to  be  included  the  fact  that  his  demon- 
stration of  the  value  of  light  as  a  therapeutic  agent  in  skin  dis- 
eases was  a  factor  in  suggesting  the  application  of  x-rays  in 
similar  conditions. 

The  use  of  x-rays  in  lupus  is,  I  think  it  may  be  safely  said, 
an  established  method  of  treatment.  Many  writers  have  given 
testimony  as  to  the  success  of  the  method  in  lupus.  Among 
those  who  have  done  valuable  work  in  this  field  may  be  men- 
tioned especially  Schiff  and  Freund,*  Gassmann  and  Schenkel,f 
Hahn  and  Albers-Schonberg,  J  Kiimmel,§  in  Germany  and 
Austria;  Scholefield,  |  Holland,**  Hall -Ed  wards,  ft  and  Star- 
tin,  JJ  in  England;  Jones,  §§  Knox,  ||||  and  Greenleaf,***  in  the 

*Wien.  med.  Wochens.,  1898,,  xlviii,  p.  1058. 
fFortschr.  a.  d.  Geb.  d.  Rontgenstrahlen,  1899,  ii,  p.  121 
J  Munch,  med.  Wochens.,  1900,  xlvii,  pp.  284,  324,  363. 
§Arch.  f.  klin.  Chir.,  1898,  Ivii,  p.  630. 
||  Brit.  Med.  Jour.,  1900,  i,  p.  1083. 
**  Liverpool  Med. -Chir.  Jour.,  1899,  xix,  p.  10. 
ft  Edinburgh  Med.  Jour.,  1900,  xlix,  p.  139. 

II  Lancet,  1901,  ii,  p.  144.  \\  Phila.  Med.  Jour.,  1900,  v,  p.  63. 

Illl  Jour.  Am.  Med.  Assoc.,  1900,  xxxv,  p.  1210. 
***  Buffalo  Med.  Jour.,  1901,  xli,  p.  189. 

371 


372  TREATMENT   OF   TUBERCULOSIS    BY    X-RAYS. 

United  States.  The  first  report  of  the  successful  treatment  of 
lupus  vulgaris  by  x-rays  in  the  United  States  was  the  very 
valuable  report  of  P.  M.  Jones,  of  California,  January, 
1900,  which  antedated  by  ten  months  any  other  scientific 
report  upon  this  subject  In  the  United  States.  The  second  case 
reported  was  that  of  Knox,  in  November,  1900.  The  third 
case  was  Case  34  in  my  series,  which  wras  reported  one  month 
later.  The  testimony  as  to  the  value  of  x-rays  in  lupus  vulgaris 
is  conclusive,  and  so  well  established  that  it  will  hardly  be 
necessary  to  go  into  the  detailed  consideration  of  the  cases 
reported. 

My  own  cases  are  typical  of  the  results  which  have  been 
obtained  in  lupus.  I  have  treated  four  successive  cases  of 
lupus  vulgaris,  in  which  sufficient  time  has  passed  to  allow 
an  opinion  to  be  formed  as  to  the  permanency  of  the  results. 

Case  34. — Mrs.  ,  aged  thirty-eight,  was  referred  to 

me  May  8,  1900,  by  Prof.  H.  B.  Favill,  of  Rush  Medical  College, 
with  a  diagnosis  of  lupus  for  treatment  with  Rontgen  rays. 
The  condition  at  that  time  is  shown  in  the  accompanying 
photograph  (Fig.  106).  The  extent  of  the  disease  on  the  left 
side  of  the  face  and  the  neck  is  indicated  in  the  photograph. 
It  also  extended  over  on  the  right  side  of  the  chin  and  up  on 
the  right  cheek  beyond  the  angle  of  the  mouth.  This  entire 
area  was  covered  with  lupous  ulcers  and  unhealthy  scars.  The 
ulcers  were  the  typical  flabby,  soft,  indolent  ulcers  of  lupus 
covered  with  reddish-brown  crusts.  The  scars  were  thick,  red, 
band-like,  and  very  disfiguring,  and  were  most  marked  under 
the  chin  ;  they  were  sufficiently  rigid  materially  to  interfere 
with  motion.  At  many  points  in  the  scars  there  were  recurrent 
ulcers.  Typical  "apple  jelly"  tubercles  of  lupus  were  easily 
demonstrable  in  any  part  of  the  diseased  area.  The  point  of 
greatest  activity  of  the  lupus  was  an  area  with  a  diameter  of 
perhaps  two  inches  around  the  left  angle  of  the  mouth.  The 
ulcers  involved  the  mucous  membrane  of  the  lips  at  this  point, 
but  no  lesions  were  found  within  the  buccal  cavity.  There 
was  no  evidence  of  tubercular  involvement  of  the  deeper  struc- 
tures. There  were  no  deep  sinuses  and  no  tubercular  glands. 
The  case  was,  in  short,  a  lupus  and  not  a  scrofuloderma. 


if. 

•  E 


it 

E 


374 


375 


LUPUS   VULGARIS.  377 

The  disease  began,  the  patient  thinks,  about  four  years  ago 
in  an  innocent-looking  ulcer  the  size  of  a  pea  on  the  neck, 
and  gradually  spread  from  that  point.  The  disease,  however, 
was  so  benign  in  appearance  that  little  attention  was  given  it 
and  no  physician  saw  it.  It  is  probable  that  it  had  existed 
some  time  before  it  attracted  notice.  The  case  had  had  no 
treatment  before  I  saw  it  except  the  application  of  salves, 
which  had  had  no  influence  on  its  course.  It  had  steadily 
progressed  from  bad  to  worse,  ulcers  healing  at  times  or  new 
ones  appearing,  but  more  tissue  constantly  becoming  affected. 
At  the  time  the  patient  appeared  for  treatment  her  general 
condition  was  considerably  run  down,  but  without  evidence 
of  other  disease  than  the  lupus.  There  was  no  indication  of 
tubercular  involvement  of  the  lungs.  She  had  had  the  usual 
diseases  of  childhood,  but  had  had  no  serious  illness  except 
an  attack  of  appendicitis  about  five  years  ago.  She  has  never, 
within  her  memory,  had  an  eruption  except  the  lupus.  As  a 
young  baby  she  is  said  to  have  had  an  eruption  of  short  duration 
after  vaccination,  which  was  probably  an  impetigo.  Her  father 
died  at  sixty -nine,  of  bladder  trouble.  Her  mother  is  living, 
aged  sixty,  but  has  been  blind  for  thirty  years  and  has  always 
been  "scrofulous."  She  has  a  brother  aged  twenty -six  and  a 
sister  aged  thirty-two,  both  in  good  health.  A  brother  aged 
twenty-three  has  a  chronic  cough.  Several  brothers  and  sisters 
died  in  childhood. 

As  to  the  diagnosis,  the  presence  of  the  pathognomonic 
tubercles,  the  indolent  ulcers  with  soft  reddish  borders,  the 
thick  band-like  scars  showing  recurrent  tubercles  and  ulcers, 
the  slow  course  and  painless  character  of  the  disease,  are  all 
characteristic  of  lupus  and  serve  to  differentiate  it  from  syphilis 
or  carcinoma.  That  the  disease  was  not  blastomycetic  derma- 
titis, which  sometimes  so  closely  resembles  lupus  clinically,  was 
shown  by  the  absence  of  blastomycetes.  I  have  sections  made 
from  a  piece  of  tissue  taken  from  the  border  of  an  active  ulcer. 
These  sections  show  the  structure  of  tuberculous  tissue.  Tuber- 
cle bacilli  were  found  in  this  tissue  by  me,  and  independently 
in  other  sections  by  Dr.  Roehr,  of  the  Columbus  Laboratory. 
I  was  fortunate  in  having  the  case  seen  by  Dr.  H.  G.  Anthony, 


378        TREATMENT  OF  TUBERCULOSIS  BY  X-RAYS. 

professor  of  dermatology  in  the  Chicago  Polyclinic,  when  it 
first  came  to  me;  he  agreed  in  the  diagnosis  of  lupus. 

Treatment  by  exposure  to  x-rays  was  begun  on  May  8,  1900, 
and  was  continued  daily,  except  Sundays,  until  May  26.  By 
May  24  many  of  the  lesions  were  clearing  up  and  beginning 
to  heal.  May  26  the  exposed  surfaces  showed  some  reaction 
from  the  effects  of  the  rays;  the  lupous  tubercles  were  brighter 
in  appearance  and  the  borders  of  the  ulcers  redder  and  swollen. 
The  changed  appearance  at  that  time  is  indicated  in  figure  107. 
Treatment  was  discontinued  until  June  4,  by  which  time  the 
reaction  had  almost  disappeared.  The  treatment  was  con- 
tinued from  June  4  until  June  21  daily  as  before,  when  con- 
siderable dermatitis  developed.  This  dermatitis  was  confined 
to  the  diseased  tissue  and  did  not  involve  the  surrounding 
healthy  skin  which  had  been  exposed  to  the  rays.  At  this 
time  the  ulcers  were  healing  rapidly.  The  treatment  was  dis- 
continued until  July  2,  when  reaction  had  entirely  disappeared 
and  almost  all  of  the  ulcers  were  healed.  From  July  2  till 
August  10  the  treatments  were  continued,  not  daily,  but  writh 
a  few  intermissions  of  three  or  four  days  as  the  condition  of 
the  face  indicated.  During  this  time  there  was  gradual  im- 
provement in  the  condition,  the  remaining  ulcers  healing, 
tubercles  being  absorbed,  and  the  entire  surface  becoming 
covered  with  healthy  scars. 

By  the  latter  part  of  July  the  left  side  of  the  face  showed 
few  traces  of  the  disease.  The  diseased  area  on  the  right  side, 
however,  which  from  the  manner  of  making  exposures  had 
received  less  of  the  effects  of  the  rays  than  the  left,  still  showed 
lupous  nodules  and  open  ulcers.  Accordingly,  additional  ex- 
posures were  begun  directly  over  this  area  on  July  30  and 
continued  daily  in  a  maximum  amount  until  August  10.  Under 
these  extra  exposures  the  lesions  immediately  began  to  improve, 
and  by  August  10  had  entirely  healed.  This  observation,  which 
is  but  confirmatory  of  similar  observations  made  by  Schiff 
and  by  Jones,  leaves  little  room  for  doubt  as  to  the  positive 
effect  of  the  rays. 

On  August  10  treatment  was  discontinued,  because  of  my 
going  away.  At  that  time  the  only  evidence  of  lupus  that  I 


LUPUS    VULGARIS.  379 

could  find  was  at  the  angle  of  the  mouth,  where  there  was 
still  a  focus  of  disease.  On  September  13  the  patient  returned ; 
there  was  then  no  evidence  of  disease  at  any  point  except  at 
the  angle  of  the  mouth  where  the  tubercles  persisted.  Treat- 
ment was  resumed  with  exposures  over  the  left  angle  of  the 
mouth.  September  20  the  tubercles  on  the  upper  lip  were 
breaking  down  and  an  elliptical  ulcer  the  size  of  a  little  finger- 
nail had  developed,  which  within  the  next  few  days  began 
to  heal.  On  October  2  some  erythema  over  the  exposed  area 
had  developed  and  treatment  was  given  up  until  October  8. 
By  October  8  the  last  lesion  had  disappeared.  From  October 
8  to  November  8  the  patient  had  daily  exposures  on  the  left 
side  of  the  chin  and  on  the  neck  under  the  chin.  These  expo- 
sures were  continued  for  two  reasons:  (1)  the  old  keloid-like 
scars  had  shown  under  the  exposures  great  improvement  in 
flexibility,  softness,  and  color,  and  it  was  desired  to  carry 
this  effect  as  far  as  possible ;  (2)  to  destroy  any  concealed  lesions 
still  present.  Since  October  8,  1900,  no  evidence  of  disease 
has  been  demonstrable.  The  results  of  the  treatment  are 
indicated  in  a  photograph  (Fig.  108)  taken  November  10,  1901. 
There  remained  no  evidences  of  the  disease  except  the  scars. 

Attention  is  called  to  the  character  of  the  scars.  The  only 
thick  ones  left  are  those  which  were  in  existence  before  the 
treatment  began,  and  they  have  become  less  prominent,  much 
softer,  and  more  pliable.  The  scars  which  have  taken  the  place 
of  the  ulcers  present  when  treatment  began  are  soft,  thin, 
flexible,  and  white,  and  are  as  healthy  looking  as  they  could 
possibly  be.  At  the  beginning  the  scars  on  the  neck  interfered 
very  considerably  with  motion ;  now  they  interfere  scarcely  at 
all.  The  last  exposure  given  this  patient  was  January  12,  1901, 
and  she  remains  well  at  the  present  time,  twenty-three  months 
later. 

Case  35. — Girl,  aged  eighteen,  referred  to  me  by  Prof.  A.  J. 
Ochsner  of  the  University  of  Illinois  with  a  diagnosis  of  lupus, 
for  treatment  with  x-rays.  This  was  a  typical  lupus  of  the  nose, 
involving  tip,  alse,  and  septum.  The  disease  began  four  years 
ago  on  the  tip  of  the  nose  and  gradually  spread  in  spite  of 
persistent  treatment.  The  patient  had  been  under  Dr.  Ochsner 's 


380        TREATMENT  OF  TUBERCULOSIS  BY  X-RAYS. 

treatment  for  two  and  a  half  months,  and  during  this  time 
the  condition  had  greatly  improved.  The  photograph  (Fig. 
109)  shows  very  well  the  condition  at  the  time  she  came  under 
my  care.  The  entire  tip  of  the  nose  and  alse  were  a  mass  of 
reddish-brown,  soft,  friable,  apple-jelly,  lupous  tissue.  The 
middle  half  was  ulcerating  and  scarred.  The  disease  had  also 
involved  the  mucous  membrane  of  the  nasal  orifices. 

Exposures  were  begun  on  October  1,  1900,  and  were  given 
almost  daily  until  December  20. 

"With  the  exception  of  a  reddening,  sharply  confined  to  the 
lupous  area,  which  occurred  after  thirty  sittings,  there  was  no 
change  in  the  condition  until  the  middle  of  December,  when 
considerable  redness  developed  in  the  lupous  tissue  and  slight 
redness  in  the  surrounding  healthy  part  which  had  been  ex- 
posed. As  the  lesions  had  proved  quite  intractable,  exposures 
were  continued  until  ten  more  were  given.  On  December  20,  after 
sixty-four  exposures,  treatment  was  stopped  on  account  of  derma- 
titis and  tenderness  of  the  exposed  surfaces;  on  December  28,  with- 
out further  exposures,  a  not  very  tense  bulla,  the  size  of  a  thumb- 
nail, developed  on  the  tip  of  the  nose,  where  the  effect  of  the 
light  had  been  greatest.  This  was  accompanied  by  tenderness 
and  slight  pain.  Within  a  week  most  of  the  dermatitis  sub- 
sided, the  bulla  ruptured,  and  at  its  site  there  showed  a  very 
superficial  ulceration.  This  bled  easily,  was  quite  painless  after 
a  few  days,  and  was  covered  with  a  superficial  necrotic  mem- 
brane. Its  borders  rapidly  contracted,  and  on  January  20  it 
had  entirely  healed.  With  the  healing  of  this  surface  almost 
all  traces  of  lupus  disappeared.  There  was  left  only  a  sus- 
picious area,  the  size  of  a  little  finger-nail,  on  the  right  ala; 
to  remove  this,  exposures  were  given,  at  from  one  to  two  days' 
interval,  during  February  and  March.  After  thirty  sittings 
this  spot  on  the  ala  of  the  nose  became  red  and  swollen,  and 
these  manifestations  were  quickly  followed  by  a  very  remarkable 
softening  of  the  lesion,  so  that  it  felt  as  soft  as  a  flaccid  bulla, 
without,  however,  any  suspicion  of  a  separation  of  the  epidermis 
occurring.  The  redness  and  softening  were  quickly  followed  by 
the  disappearance  of  the  last  suspicious  area.  From  the  begin- 
ning of  treatment  up  to  the  time  of  the  disappearance  of  the 


381 


LUPUS   VULGARIS.  383 

last  lesion,  March  16,  1901,  she  had  ninety-five  sittings,  extend- 
ing over  a  period  of  six  months.  For  two  months  after  the 
disappearance  of  the  last  lesion  she  has  had  irregular  exposures 
as  a  precaution.  The  result  of  treatment  is  shown  in  the 
photograph  (Fig.  110).  She  has  had  no  treatment  since  May  1, 
1901,  and  there  has  been  no  recurrence. 

The  result  from  a  cosmetic  standpoint  is,  I  believe,  as  perfect 
as  can  possibly  be  expected.  There  is  some  diminution  in  the 
size  of  the  nose,  but  aside  from  this  there  is  no  deformity. 
There  is  entire  absence  of  scarring  in  all  of  the  areas  treated 
by  this  method  ;  the  only  scars  are  those  on  the  upper  lip 
resulting  from  ulcers  which  healed  before  this  treatment  was 
begun.  The  skin  is  soft,  pliable,  and  natural  in  appearance. 

Case  36. — Lupus  hypertrophicus.  Mrs. ,  aged  thirty- 
eight,  fifteen  years  married,  was  referred  to  me  in  March,  1901, 
by  Dr.  A.  E.  Matthaei.  She  had  never  had  a  serious  illness 
except  vesical  calculus  and  cystitis  seven  years  ago,  which 
were  relieved  by  operation,  and  had  never  had  any  sort  of 
skin  eruption,  except  the  one  on  her  chin.  Her  history  gave 
no  suspicion  of  syphilis.  She  had  four  healthy  children  living 
and  had  had  one  miscarriage  of  a  healthy  fetus  between  the 
third  and  fourth  months.  Her  family  history  was  without  sig- 
nificance, except  that  her  father  died  at  the  age  of  forty-nine 
of  chronic  lung  trouble.  The  patient  was  sparely  built,  and 
not  very  vigorous  looking,  but  there  was  no  organic  disease. 

When  she  came  to  me,  in  March,  1901,  there  were  two  hyper- 
trophic  patches,  one  on  the  tip  of  the  chin,  the  other  under 
the  chin,  as  shown  in  figure  111.  These  consisted  of  closely 
set  groups  of  waxy,  glistening,  almost  translucent  tubercles 
which  at  a  distance  looked  very  like  patches  of  zoster.  The 
first  patch  to  develop,  the  one  under  the  chin,  appeared  about 
seven  years  ago  as  a  pinhead-sized  lesion,  around  which  other 
lesions  gradually  developed.  This  patch  was  cut  out,  but  the 
disease  recurred  in  the  scar,  and  twro  years  later  the  group  of 
lesions  appeared  on  the  tip  of  the  chin.  Since  that  time  the  dis- 
ease has  persisted  in  spite  of  treatment  and  gradually  increased 
to  the  condition  shown  in  figure  111.  The  scar  in  the  center 
of  the  patch  under  the  chin,  resulting  from  the  previous  opera- 


384        TREATMENT  OF  TUBERCULOSIS  BY  X-RAYS. 

tions,  produced  a  similarity  in  appearance  to  syphilis  which  was 
confusing. 

The  case  was  first  shown  by  me  in  March,  1901,  at  a  meeting 
of  the  Chicago  Dermatological  Society,  as  a  case  of  hypertrophic 
lupus.  There  was  then  a  difference  of  opinion  between  hyper- 
trophic  lupus  and  tubercular  syphilide.  The  case  was  afterward 
shown  at  a  meeting  of  the  American  Dermatological  Associa- 
tion, where  most  of  the  members,  I  believe,  agreed  in  the 
diagnosis  of  hypertrophic  lupus.  The  microscopic  findings  were 
not  conclusive,  and  in  order  to  exclude  syphilis,  the  case  was 
for  two  and  a  half  months  put  under  full  doses  of  iodides  and 
mercury  and  mercurial  ointment  locally.  This  treatment  had 
no  effect. 

After  the  failure  of  mixed  treatment,  the  case  was  put  under 
daily  x-ray  exposures  in  June,  1901.  The  effect  was  not  prompt, 
but  after  two  months  considerable  erythema  was  produced 
which  was  accompanied  by  marked  shrinkage  of  the  lesions. 
The  exposures  were  continued  until  August  26,  with  the  pro- 
duction of  an  acute  dermatitis,  and  by  this  time  the  tubercles 
had  shrunken  until  the  surface  was  flat.  The  dermatitis  was, 
curiously  enough,  confined  sharply  to  the  diseased  area. 

The  patient  has  been  well  since  September,  1901,  but  had 
prophylactic  exposures  at  intervals  until  March,  1902.  There  is 
no  scarring  on  the  tip  of  the  chin  and  very  little  under  the 
chin  (Fig.  112). 

Case  37. — Trained  nurse,  aged  forty-one,  with  a  very  severe 
lupus  vulgaris  of  at  least  twenty-five  years'  duration.  She  had 
been  persistently  treated,  and  in  October,  1898,  the  diseased 
area  was  removed  and  a  plastic  operation  done  for  the  restora- 
tion of  the  nose  and  of  the  central  part  of  the  face.  The  disease 
recurred  in  the  scar  and  has  since  involved  the  nose  and  all 
of  the  surrounding  skin.  The  nose  has  been  almost  entirely 
destroyed  since  the  recurrence.  This  case  was  under  treatment 
more  or  less  continuously  from  November,  1900,  until  April, 
1902,  and  during  this  time  the  disease  not  only  did  not  spread, 
but  the  area  involved  was  considerably  diminished.  At  no 
time,  however,  did  the  improvement  approximate  a  cure.  In 
April,  1902,  she  was  unavoidably  compelled  to  discontinue 


Fig.  111. — Lupus  hypertrophicus. 


Fig.  113. 


25 


385 


LUPUS   VULGARIS.  387 

treatment,  and  since  that  time  she  writes  me  she  has  grown 
very  much  worse.  This  case  must  be  regarded  as  a  failure. 
The  part  of  the  face  restored  by  the  plastic  operation  was 
extremely  susceptible  to  x-rays  and  the  healthy  tissue  seemed 
unable  to  cope  with  the  lupous  foci  in  the  way  in  which  it 
has  done  in  the  other  cases.  The  result  in  this  case  is  similar 
to  results  with  ultra-violet  rays  reported  by  Finsen  in  cases 
where  the  disease  has  recurred  after  plastic  operation. 

Case  38. — Woman,  aged  thirty-five,  with  lupus  vulgaris  of 
twenty  years'  duration.  At  the  time  of  coming  under  treat- 
ment there  was  lupus  of  the  cheeks  and  nose,  of  the  back  of 
the  right  hand,  and  the  back  of  the  right  elbow.  The  area 
on  the  face  consisted  of  old  scar  tissue,  filled  with  apple -jelly 
tubercles,  but  without  ulceration.  While  the  disease  had 
existed  for  a  long  time,  there  had  been  a  comparatively  small 
amount  of  destruction  of  tissue.  There  was  an  ulcerating  area 
of  lupus  almost  covering  the  back  of  the  right  hand.  There 
was  a  similar  ulcerating  lupous  lesion,  1^  by  1\  inches,  on 
the  back  of  the  elbow.  Between  May  19  and  September  11 
the  patient  had  48  exposures  over  the  face  with  the  production 
of  slight  dermatitis  on  two  occasions.  The  face  had  gradually 
improved  during  the  treatment,  until  on  December  1  the  change 
is  very  marked.  The  redness  has  entirely  disappeared  and  the 
scars  are  white  and  soft,  but  there  still  remain  numerous  pale 
tubercles  in  the  skin  representing  previous  typical  apple-jelly 
tubercles,  so  that  it  cannot  be  said  that  the  face  is  free  from 
disease.  The  back  of  the  right  elbow  was  given  fifteen  expo- 
sures during  August  and  September  with  the  development  of 
a  rather  acute  dermatitis,  on  the  subsidence  of  which  the 
disease  entirely  disappeared  and  left  a  healthy  scar.  At  the 
same  time  the  back  of  the  right  hand  was  given  fifteen  expo- 
sures, which  resulted  in  an  acute  weeping  dermatitis.  Since  the 
disappearance  of  this  the  hand  also  has  been  free  from  evidence 
of  lupus.  At  the  present  time,  December  1,  the  hand  and 
elbow  may  be  said  to  be  symptomatically  cured,  and  while 
the  same  cannot  be  said  of  the  face,  which  has  been  treated 
less  vigorously,  the  improvement  is  so  great  that  there  seems 
every  reason  to  believe  that  a  successful  result  will  be  attained 
there  also. 


3S8        TREATMENT  OF  TUBERCULOSIS  BY  X-RAYS. 

The  results  in  Cases  34,  35,  and  36  are  as  good  as  can  possibly 
be  hoped  for  by  any  method.  There  has  been  no  destruction 
of  healthy  tissue  in  getting  rid  of  the  disease,  and  less  scarring 
could  not  possibly  remain  after  any  lesions  as  extensive  as 
these  were.  The  scars  are  white,  soft,  and  pliable,  and  indeed 
in  Cases  35  and  36  are  hardly  to  be  called  scars  at  all.  As  to 
the  permanency  of  the  results,  Case  34  has  been  well  twenty- 
seven  months,  Case  35  twenty-one  months,  and  Case  36  fifteen 
months. 

As  said  before,  these  cases  are  typical  of  the  results  that 
have  been  obtained  by  other  workers,  and  they  can  leave  no 
doubt  of  the  value  of  this  method  of  treatment  of  lupus.  Xo 
other  method  of  treating  lupus  has  ever  shown  anything  like 
as  good  results  except  Finsen's  method  with  ultra-violet  light. 
Between  the  results  obtained  by  these  two  methods  there  is, 
I  am  convinced,  no  room  for  choice.  Both  give  excellent 
results,  both  show  scarring  of  exactly  the  same  character,  and 
there  is  no  reason  to  believe  that  either  has  any  advantage 
over  the  other  as  regards  the  permanency  of  the  results.  Per- 
haps radiotherapy  is  a  quicker  method  of  curing  these  cases 
than  phototherapy,  but  with  the  improved  lamps  now  in  use 
the  length  of  time  required  for  treatment  by  Finsen's  method 
has  been  much  reduced,  so  that  it  approximates  the  time 
required  for  treating  these  cases  by  z-rays. 

The  length  of  time  required  in  treating  these  cases  probably 
varies  considerably  according  to  the  vigor  with  which  the 
treatment  is  carried  out.  Cases  are  reported  in  which  a  few 
strong  treatments  scattered  over  several  weeks  have  proved 
sufficient.  In  my  cases  the  length  of  treatment  before  the 
disease  disappeared  in  Case  34  was  five  months;  in  Case  35, 
five  months;  in  Case  36,  four  months.  It  is  doubtful  if  any- 
thing is  gained  by  trying  to  shorten  the  time  of  treatment 
and  treating  these  patients  so  vigorously  as  to  produce  a  marked 
reaction  in  the  skin.  The  logical  course  to  pursue  is  to  get 
up  a  sufficient  reaction  to  cause  degeneration  of  the  diseased 
tissue  without  destructive  effect  upon  the  healthy  stroma.  In 
Case  34  in  my  series  it  was  found  unnecessary  to  cause  more 
than  the  faintest  ervthema.  In  Case  35  most  of  the  disease 


LUPUS    VULGARIS.  389 

disappeared  without  the  production  of  more  than  a  moderate 
dry  dermatitis,  but  to  get  rid  of  the  last  lesion  it  was  found 
necessary  to  carry  the  reaction  to  the  point  of  producing  a 
bulla.  In  Case  36  the  reaction  was  carried  to  the  point  of 
producing  an  acute  dermatitis  on  several  occasions. 

Upon  this  point  Scholtz  *  has  observed  that  "  neither  that 
method  of  treatment  which  avoids  any  inflammatory  reaction, 
nor  that  in  which  a  severe  reaction  is  produced,  can  be  said 
to  be  the  best  for  all  cases  of  lupus ;  nowhere  is  the  personal 
application  of  treatment  a  more  necessary  consideration  than 
with  x-rays.  Our  observations  have  shown  that  energetic 
treatment  leading  to  superficial  excoriation  and  necrosis  is 
more  effective  than  slight  exposure.  The  process  of  healing — 
molecular  destruction  of  the  tubercles,  reactive  inflammation, 
replacement  of  the  lupous  tissue  by  new  connective  tissue — 
is  much  the  same  whether  exposures  be  severe  or  slight.  But 
in  the  former  case  the  reaction  is  more  active  and  the  process 
penetrates  more  deeply.  Choice  between  these  two  methods 
must  depend  on  the  severity  of  the  lupus,  on  its  locality,  and 
on  the  convenience  of  the  patient."  He  further  adds  that 
in  very  superficial  cases  they  sought  to  avoid  serious  x-ray 
dermatitis,  producing  only  a  slight  redness.  The  greater  num- 
ber of  their  cases,  however,  were  severe,  and  in  these  they  pro- 
duced superficial  necrosis  through  intense  exposures.  In  such 
cases  they  found  that  the  sores  produced  caused  very  little  pain, 
were  easily  handled,  healed  in  a  few  weeks,  and  their  scars  were 
soft  and  smooth,  and  the  cosmetic  result  not  appreciably  worse 
than  when  the  treatment  was  less  vigorously  carried  out.  They 
always  undertook  to  avoid  deep  necrosis,  but  their  experience 
led  them  to  believe  that  there  was  no  reason  to  beware  of  a, 
superficial  necrosis.  In  my  cases  I  have  never  found  it  neces- 
sary to  carry  the  reaction  to  the  point  of  producing  even  a  super- 
ficial necrosis,  and  I  see  nothing  that  would  be  attained  by  such 
reaction  that  could  not  as  well  be  attained  by  the  simple  produc- 
tion of  an  acute  weeping  dermatitis.  I  believe  the  best  method 
of  procedure  in  all  these  cases  is  first  to  see  if  the  results  cannot 
be  obtained  by  producing  a  moderate  reaction,  and  only  after 

*Arch.  f.  Derm.  u.  Syph.,  1902,  lix,  p.  421. 


390        TREATMENT  OF  TUBERCULOSIS  BY  X-RAYS. 

this  fails  to  resort  to  radical  exposures.  It  certainly  is  not 
necessary  in  most  cases  to  cause  ulceration  of  the  lupous  tuber- 
cles in  order  to  get  rid  of  them. 

Schiff  and  Freund  *  called  attention  to  the  shrinking  without 
ulceration  of  the  lupous  tubercles,  and  this  observation  has 
been  confirmed  by  numerous  writers.  In  none  of  my  cases 
have  I  seen  a  lesion  disappear  by  ulceration.  They  shrink, 
lose  their  color,  and  disappear,  leaving  a  healthy  looking  scar, 
or  no  scar,  without  breaking  down. 

There  is  universal  testimony  as  to  the  cosmetic  excellence 
of  the  scars  from  this  method  of  treating  lupus,  just  as  from 
the  treatment  by  Finsen's  method.  The  scars  are  soft,  white, 
and  pliable,  and  show  none  of  the  keloid-like  character  that 
we  have  been  accustomed  to  see  in  lupous  scars  heretofore. 
Moreover,  the  scars  left  by  lupus  which  has  disappeared  spon- 
taneously or  under  other  methods  of  treatment  have  in  many 
cases  been  found  to  show  marked  improvement  after  exposure 
to  x-rays.  This  is  well  illustrated  in  the  very  great  improve- 
ment in  the  pliability  and  thickness  of  the  scars  of  the  neck 
in  Case  34  of  my  series. 

In  my  cases  the  only  other  treatment  that  the  patients  have 
had  has  been  surgical  cleanliness.  This  is  in  accord  with  the 
reports  of  most  other  observers,  who  have  agreed  that  the 
x-rays  have  proved  sufficient  without  the  aid  of  other  local 
treatment.  When  one  remembers  how  trying  the  usual  methods 
of  treatment  are,  the  fact  that  their  aid  is  not  necessary  does 
not  appear  as  the  least  of  the  advantages  of  the  treatment  of 
lupus  by  radiotherapy. 

Tuberculous  Ulcers  and  Scrofuloderma. — In  tuberculous  ulcers 
and  in  scrofuloderma,  using  that  term  to  describe  the  diseased 
conditions  of  the  skin  and  subcutaneous  tissues  that  are  asso- 
ciated with  tubercular  glands  and  other  deep-seated  foci  of 
tuberculosis,  there  are  good  grounds  for  the  use  of  x-rays,  but 
as  yet  the  literature  contains  little  upon  the  subject. 

Lortet  and  Genoud  f  have  reported  their  findings  in  eight 
guinea-pigs  inoculated  in  the  inguinal  region  with  tuberculosis. 

*Wien.  klin.  Wochens.,  1900,  xiii,  p.  827. 
fSemaine  med.,  1396,  xvi,  p.  266. 


TUBERCULOUS    ULCERS    AND    SCROFULODERMA.  391 

Of  these,  three  that  had  x-ray  exposures  after  inoculation  did 
not  develop  tuberculosis,  while  in  the  five  other  pigs,  which  were 
not  exposed  to  x-rays,  tuberculous  ulcers  developed  at  the  points 
of  inoculation. 

Miihsam  *  concluded,  so  long  ago  as  1898,  from  experiments 
on  guinea-pigs,  that  x-rays,  while  exercising  no  influence  on 
general  tuberculosis,  restrained  local  tuberculosis  to  a  point 
where  its  action  was  very  slight. 

Williams  f  has  reported  a  case  of  tuberculosis  of  the  dorsal 
surface  of  the  foot  treated  by  x-rays,  in  which  there  was  a 
microscopic  diagnosis  of  tuberculosis.  The  lesion  involved  the 
dorsum  of  the  fourth  and  fifth  toes  and  the  contiguous  surface. 
Under  ten  exposures  to  x-rays,  varying  from  five  to  fifteen 
minutes  in  length,  the  pain  entirely  ceased  and  the  growth 
in  great  part  disappeared. 

Bagge  |  has  reported  an  extensive  ulcerating  tuberculous 
lesion  extending  from  the  front  of  a  man's  chest  around  under 
the  axilla  to  the  back,  which  had  developed  from  a  burn  infected 
by  tuberculosis  and  had  remained  unhealed  for  seventeen 
years.  The  area  was  treated  by  x-ray  exposures,  and  in  three 
weeks  the  entire  surface  healed. 

Case  39. — I  have  treated  one  ulcer  of  the  leg,  probably  tubercu- 
lous. Mrs. ,  aged  twenty-five,  referred  to  me  by  Dr.  William 

Cuthbertson,  of  Chicago,  with  a  tuberculous  ulcer  on  the  back 
of  the  middle  third  of  the  leg,  four  inches  in  vertical  diameter 
and  two  in  transverse,  and  quite  deep.  This  ulcer  had  per- 
sisted for  ten  months  in  spite  of  most  vigorous  treatment. 
The  patient  was  run  down  physically,  but  had  no  evidence 
of  tuberculosis  elsewhere.  She  was  put  under  x-ray  expo- 
sures August,  1901,  and  these  were  continued  daily  for  two 
months,  and  after  that  irregularly  until  December  23,  1901. 
At  the  end  of  two  weeks  the  lesion  began  to  clear  up  and  show 
healthy  granulations.  In  two  weeks  more  it  was  reduced  to 
one-half  its  previous  size,  and  by  November  1,  1901,  was  entirely 
healed  with  a  healthy  looking  scar.  During  this  time  the 

*Deut.  med.  Wochens.,  1898,  xxiv,  p.  715. 

t  "The  Rdntgen  Rays  in  Medicine  and  Surgery,"  p.  662. 

JFortschr.  a.  d.  Geb.  d.  Rontgenstrahlen,  1899,  iii,  p.  218. 


392  TREATMENT    OF   TUBERCULOSIS    BY    X-RAYS. 

patient  was  on  crutches,  but  used  the  leg  slightly.  In  March, 
1902,  the  disease  recurred  in  the  scar,  and  at  the  present  time 
is,  I  believe,  as  extensive  as  it  ever  was,  although  she  has  been 
having  some  x-ray  exposures. 

Sjogren  and  Sederholm  *  have  reported,  under  the  title  of 
tuberculides  or  scrofuloderma,  five  cases  which  have  shown 
improvement  without  entire  cure  under  x-ray  exposures. 
These  cases,  however,  are  not  the  cases  usually  classed  under 
scrofuloderma,  but  are  cases  showing  cyanotic  nodular  lesions 
on  the  extremities  in  scrofulous  subjects,  and  are  usually  em- 
braced under  the  title  scrofulides  or  tuberculides.  They  are 
hardly  entitled  to  weight  in  considering  the  effect  of  x-rays 
on  tuberculosis  of  the  skin,  until  we  know  more  of  their  essential 
character  than  is  known  at  present. 

Williams  f  refers  to  two  cases  of  tuberculous  sinuses  of  the 
neck,  of  which  Dr.  F.  M.  Briggs  has  given  him  a  personal  report, 
that  have  been  greatly  benefited  by  treatment  with  x-rays. 
One  case,  a  boy  fourteen  years  old,  had  a  long-standing  sup- 
purating adenitis  of  the  cervical  glands,  which  had  resisted 
operative  treatment  for  eight  months.  There  was  one  sinus 
opening  on  both  sides  of  the  neck.  The  case  was  put  under 
x-ray  treatment,  and  after  six  exposures  the  opening  on  one 
side  had  closed,  and  there  was  only  a  small  amount  of  dis- 
charge from  that  on  the  other  side.  At  the  time  of  report  the 
patient  was  still  under  treatment. 

The  second  case  was  that  of  a  boy  eight  years  old  who  had  a 
freely  discharging  sinus  on  one  side  of  the  neck  of  nineteen 
months'  duration  in  spite  of  constant  treatment.  After  two 
x-ray  exposures  the  sinus  stopped  discharging,  and  it  had  not 
reopened  at  the  time  of  the  report. 

Case  40. — I  have  treated  one  case  of  scrofuloderma  with 
cervical  adenitis,  referred  to  me  by  Prof.  A.  J.  Ochsner,  of 
the  University  of  Illinois.  This  patient,  a  girl  twenty-four 
years  old,  had  had  several  operations  for  tuberculous  glands 
on  either  side  of  the  neck  and  in  either  axilla.  The  last  opera- 
tion was  November  5,  1901,  when  a  mass  of  tuberculous  glands 

*  Fortschr.  a.  d.  Geb.  d.  Rontgenstrahlen.  1901.  iv,  p.  145. 
t  "The  Rontgen  Rays  in  Medicine  and  Surgery,"  p.  664. 


TUBERCULOUS   VESICAL    FISTULA.  393 

was  removed  from  the  right  axilla  and  a  small  fluctuating 
mass  from  the  neck  below  the  right  mastoid  process.  The 
wound  in  the  neck  refused  to  heal,  and  on  November  21,  1901, 
when  she  was  referred  to  me  for  x  -ray  treatment,  there  was 
a  deep  sinus  on  the  right  side  of  the  neck  and  the  tissues  pre- 
sented the  usual  appearance  of  scrofuloderma.  The  scar  tissue 
on  both  sides  of  the  neck  was  unhealthy  looking,  dense  and 
inelastic,  and  there  were  several  suspicious  indurated  masses 
on  either  side.  From  November,  1901,  to  March,  1902,  she 
had  30  exposures,  when  the  sinus  healed  and  the  scar  tissue 
in  every  way  took  on  a  much  more  satisfactory  appearance. 
Since  that  time  she  has  had  exposures  at  average  intervals  of 
a  week  and  the  improvement  has  remained.  It  is  not  possible 
to  say  that  the  case  is  entirely  cured,  but  there  are  no  sinuses 
or  evidences  of  adenitis,  the  scar  tissue  in  the  neck  is  healthy 
looking,  and  much  softer  and  more  pliable  than  at  the  begin- 
ning of  treatment.  In  view  of  the  previous  history  of  the  case 
and  its  condition  at  the  time  of  the  beginning  of  treatment 
there  can  be  little  doubt  of  the  marked  benefit  derived  from 
the  treatment.  The  patient  still  has  exposures  once  a  week. 

Tuberculous  Vesical  Fistula. — I  have  treated  one  vesical  fistula 
opening  upon  the  right  buttock,  resulting  from  tuberculosis 
of  the  deep  urethra  and  bladder,  in  a  man  aged  forty,  referred 
to  me  by  Dr.  T.  A.  Davis,  of  the  University  of  Illinois.  This 
patient  had  sixty  x-ray  exposures  between  April  25  and  August 
1,  1902.  The  reaction  was  carried  to  the  point  of  producing 
pigmentation  and  slight  dermatitis  on  several  occasions.  The 
induration,  which  was  quite  marked  about  the  fistula  at  the 
beginning  of  treatment,  became  unquestionably  very  much  less, 
but  aside  from  that  there  was  little  improvement  and  the 
patient  discontinued  treatment. 

Tuberculous  Glands. — There  is  reason  to  think  that  a  very 
general  attempt  is  being  made  at  the  treatment  of  tuberculous 
cervical  adenitis  by  x-rays,  but  there  is  as  yet  little  literature 
upon  the  subject. 

Williams*  states  that  enlarged  cervical  glands,  even  when 

*  "The  Rontgen  Rays  in  Medicine  and  Surgery,"  p.  674. 


394  TREATMENT    OF   TUBERCULOSIS    BY    X-RAYS. 

of  great  size,  respond  surprisingly  well  to  treatment  by  x-rays, 
but  reports  no  cases. 

In  a  personal  communication  to  the  writer  Dr.  H.  A.  Bren- 
necke,  of  Aurora,  111.,  has  reported  the  entire  disappearance 
of  a  very  large  mass  of  cervical  glands  in  the  neck  of  a  girl 
fifteen  years  old,  whom  I  saw  with  him  before  the  beginning 
of  treatment. 

In  addition  to  Case  40,  referred  to  above,  under  scrofuloderma 
treated  by  me,  I  have  treated  the  following  cases  of  tuberculous 
glands  of  the  neck: 

Case  41. — Miss  ,  aged  seventeen,  with  tuberculous 

family  history.  One  tuberculous  gland  was  removed  June, 

1901.  At  the  time  she  came  to  me  for  treatment  there  was 
a  gland  the  size  of  a  filbert  on  the  left  side  of  the  neck  two 
inches  above  the  clavicle.     On  the  right  side  there  was  a  group 
of  painless  glands  five  or  six  in  number,  the  smallest  the  size 
of  a  split  pea,  the  largest  the  size  of  a  filbert.     Between  Feb- 
ruary 15  and  March  28,  1902,  she  received  twenty  exposures 
over  these  glands  on  either  side,  with  the  production  at  one 
time  of  an  acute  dermatitis.     In  this  time  there  was  certainly 
decided  diminution  in  the  size  of  the  glands,  but  the  patient 
was  careless  of  treatment  and  discontinued  it  without  relief. 

Case  42. — Man,  aged  twenty-five,  who  two  years  before  had 
an  operation  for  the  removal  of  tuberculous  glands  on  the  right 
side  of  the  neck.  At  the  time  of  coming  for  treatment,  June, 

1902,  there  was  a  gland  the  size  of  an  olive  at  the  upper  border 
on  the  sternocleidomastoid  muscle.     After  15  exposures  in  two 
months  dermatitis  developed,  since  the  subsidence  of  which 
exposures  have  been  given  at  one  period  to  the  point  of  pro- 
ducing a  dermatitis  again,  and  since  that  time  at  intervals  of 
a  week.     After  the  development  of  the  first  dermatitis  the  gland 
broke  down  and  its  contents  were  evacuated  by  an  incision. 
Under  subsequent  exposures  the  cavity  filled  up  with  healthy 
granulations  and  a  healthy  scar  formed.     The  case  is  still  having 
occasional  x-ray  exposures. 

Case  43. — Miss ,  aged  thirty,  with  tuberculous  glands 

of  the  neck,  of  several  years'  duration.  At  the  time  of  coming 
to  me  for  treatment  there  was  a  mass  of  non-fluctuating  glands 


TUBERCULOSIS   OF   LARYNX.  395 

on  the  right  side  of  the  neck  as  large  as  a  fist;  on  the  left  side 
a  number  of  glands  as  large  as  a  filbert.  The  patient's  general 
health  has  run  down  considerably  during  the  past  year,  when 
the  disease  has  been  at  its  worst.  At  the  time  of  coming  under 
treatment  she  was  fifteen  pounds  below  her  weight  of  a  year 
before.  This  patient  has  been  under  x-ray  exposures  at  intervals 
from  June  19  to  November  1,  with  the  production  of  pig- 
mentation and  erythema  on  several  occasions.  During  this 
time  the  glands  have  decreased  decidedly  and  become  much 
softer,  and  the  circumference  of  the  neck  has  decreased  an  inch, 
but  on  neither  side  have  the  glands  as  yet  disappeared. 

Case  44. — Girl,  aged  twenty,  with  tuberculous  cervical  adenitis 
of  several  years'  duration.  There  was  a  dense  hard  mass  of 
glands  as  large  as  a  fist  on  the  right  side  of  the  neck  and  a 
mass  little  smaller  on  the  left  side.  Between  May  27  and  July 
28,  1902,  she  had  almost  daily  exposures  on  either  side  of  the 
neck.  Then  erythema  developed  and  exposures  were  discon- 
tinued for  a  month.  Between  September  2  and  November  1  she 
had  forty  exposures.  On  several  occasions  a  slight  dermatitis 
has  been  produced  which  has  promptly  disappeared  on  rest. 
There  has  been  distinct  improvement  in  this  case.  The  swelling 
of  the  neck  has  very  nearly  disappeared.  The  right  side  of  the 
neck  is  of  almost  normal  contour,  but  still  shows  a  number  of 
fairly  hard  nodules,  the  largest  the  size  of  a  small  filbert.  The 
left  side  shows  slight  swelling  just  below  the  ear,  due  to  a  soft 
mass  the  size  of  an  almond  kernel. 

Tuberculosis  of  Larynx. — The  use  of  x-rays  in  tuberculosis  of 
the  larynx  is  also  being  tried  quite  extensively,  there  is  reason 
to  believe,  but  nothing  definite  upon  the  subject  has  as  yet  been 
reported.  Ravillet  *  has  reported  benefit  in  one  case  of  tuber- 
culous laryngitis  while  under  x-ray  exposures. 

Tuberculosis  of  Joints. — Leigh  f  has  reported  a  case  of  tubercu- 
losis of  the  elbow-joint  which  was  considered  to  require  operation 
but  was  exposed  two  or  three  times  weekly  for  two  hours  to 
x-rays.  After  six  exposures  the  inflammation  disappeared  com- 
pletely and  there  has  been  no  recurrence  in  eighteen  months. 

*  Revne  de  la  Tuberculose,  April,  1897. 
f  American  X-ray  Jour.,  1899,  iv,  p.  559. 


396        TREATMENT  OF  TUBERCULOSIS  BY  X-RAYS. 

Tuberculosis  of  Genito-urinary  Tract. — The  method  deserves  a 
trial  in  tuberculosis  of  the  genito-urinary  tract, — particularly  in 
cases  in  which  little  is  to  be  expected  of  surgery, — but  there 
are  as  yet  no  reports  in  the  literature  upon  this  subject. 

In  all  of  these  forms  of  tuberculosis, — tuberculous  sinuses  and 
ulcers,  tuberculous  adenitis,  tuberculosis  of  larynx,  and  tubercu- 
losis of  joints, — there  is  enough  ground  for  hoping  for  some 
benefit  to  justify  a  thorough  trial  of  the  method,  since  the  cases 
are  otherwise  so  difficult  of  relief.  In  tuberculous  glands  of 
the  neck  the  method  is  in  my  opinion  entitled  to  a  very  thorough 
trial  before  operation,  particularly  in  view  of  the  radical  char- 
acter of  operations  necessary  in  these  cases  and,  even  with  such 
operations,  the  unsatisfactory  character  of  the  results.  In  tuber- 
culosis of  the  larynx  and  of  the  joints  the  method  offers  sufficient 
grounds  for  expecting  benefit  to  warrant  its  use  as  an  auxiliary 
to  other  treatment. 

Abdominal  Tuberculosis. — Scholtz  *  and  Miihsam  f  have  con- 
cluded, independently,  from  experimental  inoculation  of  tubercu- 
losis in  guinea-pigs,  that  x-rays  have  no  effect  on  general  tubercu- 
losis. 

On  the  other  hand,  Ausset  and  Bedart  J  have  reported  two 
cases  most  interesting  in  this  connection.  First  the  case  of  a 
girl  with  chronic  tuberculous  peritonitis,  with  ascites  and  casea- 
tion,  which  was  presented  to  the  Societe  de  Medecine  du  Xord 
in  1898.  After  unsuccessful  attempts  at  treatment  in  various 
ways,  including  laparotomy,  the  patient  was  relieved  by  x-ray 
exposures,  and  has  remained  cured  for  eighteen  months.  They 
later  presented  the  case  of  a  girl  four  years  old  with  chronic 
tuberculous  peritonitis.  Several  members  of  the  society  con- 
curred in  the  diagnosis.  The  case  showed  all  the  classical 
symptoms;  circumference  of  the  abdomen  64.5  cm.,  liver  three 
fingers  below  the  costal  line.  By  exploratory  puncture  a  gram 
of  clear  brown  fluid  was  withdrawn.  She  was  given  x-ray 
sittings  each  second  day  for  fifty-five  days,  at  first  for  eight 
minutes,  with  the  tube  at  25  cm.  from  the  abdomen,  later  for 

*Arch.  f.  Derm.  u.  Syph.,  1902,  lix,  p.  78. 
fDeut.  med.  Wochens.,  1898,  xxiv,  p.  715. 
J  Echo  medicale  du  Xord,  1899,  iii,  p.  G04. 


ABDOMINAL  TUBERCULOSIS.  397 

fifteen  minutes  with  the  tube  at  15  cm.  On  the  twenty-first 
day  the  circumference  of  the  abdomen  began  to  diminish;  on 
the  fifty-fifth  day  it  was  56  cm.  and  all  liquid  had  disappeared. 
The  sittings  being  interrupted  for  two  months,  the  circumference 
increased  to  59  cm.  The  sittings  were  then  resumed  for  five 
weeks  and  the  case  dismissed  with  abdominal  circumference  56 
cm.,  no  ascites,  liver  two  fingers  below  the  costal  line,  and 
weight  increased  from  16.5  k.  to  19  k.  The  patient  had  abso- 
lutely no  treatment  other  than  x-ray  exposures,  and  only  her 
customary  diet. 

In  personal  communications  to  the  writer,  Professors  Frank 
Billings  and  Henry  B.  Favill,  of  Rush  Medical  College,  have 
reported  their  use  of  x-rays  in  conjunction  with  other  treatment, 
including  rest,  in  cases  of  tuberculous  peritonitis ;  in  these  cases 
there  has  been  marked  improvement,  but  how  much  of  it  is 
attributable  to  the  use  of  x-rays  they  think  it  is  impossible  to 
say. 

Case  45. — I  have  used  x-ray  exposures  in  one  case  of  chronic 
mesenteric  tuberculosis  of  a  not  severe  type,  in  a  child  eight 
years  old,  referred  to  me  by  Dr.  L.  L.  McArthur,  of  Chicago. 
In  this  case  the  exposures  were  continued  daily  from  May  7 
to  June  14,  1902.  A  very  hard  tube  was  used  and  the  surface 
protected  by  an  aluminum  screen.  Exposures  were  kept  at  a 
point  which  caused  decided  pigmentation  of  the  skin  without 
dermatitis.  June  14  the  exposures  were  discontinued  and  the 
child  taken  to  the  country.  Four  months  after  discontinuing 
treatment  Dr.  McArthur  and  Dr.  Frank  Billings  reported  that 
the  masses  were  unquestionably  diminished  in  size,  but  whether 
this  is  attributable  to  the  summer  outing  or  to  the  x-rays,  or 
to  both,  it  is  impossible  to  say. 

Pulmonary  Tuberculosis. — Some  attempt  has  been  made  at 
the  treatment  of  pulmonary  tuberculosis  with  x-rays,  but  without 
results  that  are  convincing.  Bergonie  and  Mongour,  quoted  by 
Dollinger,*  state  that  in  two  cases  of  acute  pulmonary  tubercu- 
losis in  well-nourished  individuals,  reduced  in  strength  by 
alcoholic  excesses,  no  results  were  obtained  by  exposure  to 
x-rays.  In  one  case  of  slow  pulmonary  tuberculosis  there  was 

*Fortschr.  a,  d.  Geb.  d.  Rontgenstrahlen,  1898,  ii,  p.  70. 


398        TREATMENT  OF  TUBERCULOSIS  BY  X-RAYS. 

no  effect.  In  a  second  case  there  occurred  rapid  improvement 
of  the  general  condition  without  change  in  the  local  condition. 
In  a  third  case  there  was  local  and  general  improvement  for 
a  month,  when  there  was  a  severe  attack  of  indigestion  followed 
by  aggravation  of  the  disease. 

Rudis-Jicinsky  *  has  used  x-rays  as  an  adjuvant  to  other 
treatment  of  pulmonary  tuberculosis,  and  reports  that  "from 
nineteen  selected  cases,  in  one  year,  one  died  from  intestinal 
tuberculosis,  four  proved  complete  failures  and  the  rest  were 
doing  comparatively  well." 

Reports  of  other  cases  of  pulmonary  tuberculosis  treated  by 
x-rays  have  been  made  by  Oilman, f  Burdick,|  and  Sinapius.§ 

On  the  other  hand  Havas  ||  has  concluded,  on  what  seems 
insufficient  evidence,  that  x-ray  exposures  caused  the  assumption 
of  virulence  by  a  latent  tuberculosis. 

There  is  perhaps  some  ground  for  hoping  for  benefit  from 
the  use  of  x-rays  as  an  auxiliary  to  other  treatment  in  pulmonary 
and  abdominal  tuberculosis.  It  is  not  beyond  reason  that 
throwing  x-rays  day  after  day  through  the  thorax  or  the  abdo- 
men might  be  of  service  in  the  treatment  of  tuberculosis  of 
these  parts.  And  since  the  treatment  can  be  carried  out  without 
danger  or  inconvenience  to  the  patient,  and  without  interfering 
with  approved  methods  of  treatment,  it  would  seem  that  the 
method  is  worthy  of  trial.  It  certainly  does  not  hold  out 
sufficient  hopes  of  relief  to  warrant  its  use  at  the  expense  of 
residence  in  a  bad  climate,  or  abandonment  of  better  tried 
measures.  There  is,  in  my  opinion,  no  ground  for  believing 
that  it  is  likely  to  increase  the  virulence  of  the  process. 

Syphilis. — Kiimmell  **  and  Hahn  and  Albers-Schonberg  ft 
have  each  reported  one  case  of  gummatous  syphilide,  mistaken 
for  lupus,  treated  unsuccessfully  by  x-rays.  In  both  cases  the 
fact  that  no  improvement  occurred  under  x-ray  exposures  led 
to  correct  diagnosis. 

*>iew  York  Med.  Jour.,  1901,  Ixxiii,  p.  364.     fClinique,  1897,  xviii,  p.  360. 

J  Am.  Electro- Therapeutic  and  X-ray  Era,  1902,  ii.  No.  3,  p.  1. 

\  "The  Rontgen  Rays  in  Medicine  and  Surgery,"  p.  418. 

||  Arch.  f.  Derm.  u.  Syph.,  1900,  Festschrift  Kaposi,  p.  275. 

**  Arch.  f.  klin.  Chir.,  1898,  Ivii,  p.  630. 

ft  Munch,  med.  Wochens.,  1900,  xlvii,  284,  324,  363. 


LEPROSY — BLASTOMYCETIC    DERMATITIS.  399 

I  have  exposed  cases  of  ulcerating  tubercular  syphilides  to 
x-rays  while  giving  at  the  same  time  potassium  iodide.  All  of 
the  lesions,  of  course,  rapidly  cleaned  up  under  the  iodides, 
and  I  have  not  been  able  to  see  that  the  x-rays  particularly 
influenced  the  result.  Syphilitic  ulcers  can  be  cleaned  up  like 
any  other  infected  ulcers  by  x-ray  exposures,  but  not  more 
quickly  than  they  can  be  cleaned  up  by  the  usual  wet  dressings. 
Indolent,  sluggish,  syphilitic  ulcers  could  doubtless  be  given  the 
needed  stimulation  by  exposing  them  to  x-rays.  Perhaps  this 
could  be  better  done  in  certain  intractable  cases  by  x-ray  ex- 
posures than  by  the  usual  methods  of  stimulation;  but  further 
than  this — and  this  is  not  an  important  role — it  is  doubtful 
if  x-rays  have  any  role  to  play  in  the  treatment  of  gummatous 
syphilides.  There  is  certainly  no  reason  to  substitute  x-rays  for 
the  efficient  method  of  treating  these  lesions  that  we  already 
have. 

Leprosy. — Sequeira  *  has  reported  a  case  of  tubercular  leprosy 
of  the  skin  which  has  shown  marked  improvement  under  x-rays, 
the  hard  nodules  softening  and  flattening  down. 

Allen  f  has  been  treating  a  case  of  leprosy  with  x-rays  with 
perhaps  some  improvement. 

Scholtz  |  reports  that  in  two  cases  of  leprosy  under  treatment 
with  x-rays  no  definite  results  have  as  yet  been  obtained. 

Actinomycosis. — From  the  effect  in  similar  conditions  there 
is  good  reason  to  warrant  the  trial  of  x-rays  in  the  treatment 
of  actinomycosis,  but  there  are  no  reports  upon  the  subject 
in  the  literature. 

Blastomycetic  Dermatitis. — In  a  personal  communication 
Montgomery  has  reported  that  he  and  Hyde  have  treated  some 
cases  of  blastomycosis  successfully  by  the  use  of  x-rays  locally, 
and  moderate  doses  of  potassium  iodide  internally.  I  have 
treated  one  case  of  probable  blastomycosis,  Case  142,  page 
532,  by  the  use  of  x-rays  and  the  internal  administration  of 
potassium  iodide  in  ten-grain  doses  three  times  daily.  This  case 

*Brit.  Med.  Jour.,  1901,  ii,  p.  851. 

fN.  Y.  State.  Jour,  of  Med.,  1902,  ii,  p.  176. 

{  Arch.  f.  Derm.  u.  Syph.,  1SX)2,  lix,  p.  421. 


400        TREATMENT  OF  TUBERCULOSIS  BY  X-RAYS. 

was  a  complete  success,  but  the  diagnosis  is  not  conclusively 
established. 

Case  45a. — I  have  under  treatment  at  present  one  case  of 
blastomycetic  dermatitis  involving  the  lower  eyelid,  which  is  a 
typical  beginning  case,  and  in  which  the  diagnosis  is  fully 
established.  Under  small  doses  of  potassium  iodide  three  times 
daily,  and  with  x-ray  exposures  to  the  point  of  producing  an 
erythema,  the  disease  has  almost  but  not  quite  disappeared. 
There  seems  every  reason  to  believe  that  a  completely  satis- 
factory result  will  be  obtained.  The  patient  has  only  had 
small  doses  of  potassium  iodide,  ten  grains  three  times  daily, 
which  is  not  sufficient  to  account  for  the  very  great  improve- 
ment. The  condition  at  the  time  of  beginning  treatment  and  the 
changes  under  treatment  are  shown  in  figures  113, 114,  and  115. 


401 


CHAPTER  XI. 
CUTANEOUS  CARCINOMA, 

Carcinoma. — The  most  important  and  the  most  startling 
application  which  has  been  made  of  x-rays  is  their  successful 
use  in  some  malignant  diseases.  The  first  case  *  of  malignant 
disease  treated  by  x-rays  was  a  cutaneous  carcinoma — a  rodent 
ulcer — which  was  treated  by  Stenbeck,  f  of  Stockholm,  and  dem- 
onstrated on  December  19,  1899.  Several  reports  upon  the 
use  of  x-rays  in  the  treatment  of  carcinoma  were  published 
during  the  subsequent  year,  and  the  method  began  to  attract 
attention.  During  the  last  eighteen  months  the  use  of  the 
method  in  the  treatment  of  malignant  diseases  has  increased 
by  leaps  and  bounds  until  now  it  is  being  given  the  widest 
trial.  It  is  accordingly  an  extremely  important  matter  to 
determine  the  extent  and  the  limitations  of  use  of  x-rays  not 
only  in  carcinoma  but  in  other  malignant  diseases  as  well. 

The  number  of  recorded  cases  of  carcinoma  treated  by  x-rays 
is  surprisingly  large,  and  a  review  of  them  is  of  the  highest 
interest.  The  number  of  my  successive  cases  of  carcinoma 
which  have  interest  upon  this  subject  and  which  I  have  to 
report  is  eighty-three. 

Cutaneous  Carcinoma  or  So-called  Epithelioma. — Many  writers 
have  reported  results  in  the  treatment  of  epithelioma.  Among 
these  may  be  mentioned — in  America,  Johnson  and  Merrill,J 

*  In  the  Bibliotheca  medica,  Abtheilung  D  II,  Heft  8,  1900,  Dr.  Magnus 
Holier,  in  his  article  "  Der  Einfluss  des  Lichtes  auf  den  Haut  in  gesundem  und 
krankem  Zustande,"  mentions  a  case  of  epithelioma  treated  by  the  ar-rays  by 
Sjogren.  Stenbeck,  in  a  note  to  his  article,  "  Ein  Fall  von  Hautkrebs  geheilt 
durch  Behandlung  mit  Rontgenstrahlen  "  (Mittheilungenausden  Grenzgebieten 
d.  Med.  u.  Cliir.,  1900,  vi,  p.  147),  states  that  this  case  of  Sjogren's  was  exhibited 
at  a  meeting  of  the  Swedish  Medical  Society,  Dec.  19,  1899,  not  yet  cured,  at 
the  same  time  that  he  (Stenbeck)  demonstrated  his  case  cured. 

fMittheilungen  a.  d.  Grenzgeb.  d.  Med.  u.  Chir.,  1900,  vi,  p.  347. 

£  Phila.  Med.  Jour.,  1900,  vi,  p.  1089.  American  Medicine,  1902,  iv,  p.  217. 

403 


404  CUTANEOUS    CARCINOMA. 

Williams,*  Beck,t  Rinehart,  J  Morton, §  Hett,  ||  Hopkins,** 
Allen, ft  Duncan  ;JJ  in  England,  Taylor,  §§  Ferguson,  ||  ||  Se- 
queira,*f  Startin;  *J  in  other  parts  of  Europe,  Stenbeck,*§ 
Sjogren  and  Sederholm,*  [|  Scholtz.f* 

One  or  more  cases  symptomatically  cured  have  been  reported 
by  BeckfJ  one,  Taylor  f§  one,  Ferguson  f||  one,  Hett  J*  four, 
Rinehartjf  four,  Third  J§  two,  Scholtz  J||  one,  Morton  §*  one, 
C.  W.  Allen §f  three,  Sjogren  and  Sederholm  §J  four,  Everett 
Smith  §||  one,  S.  Allen  ||*  one,  Pfahler||f  three. 

Williams  has  reported  seven  cases  of  epithelioma  symptomati- 
cally cured  and  four  in  which  there  has  been  rapid  improvement . 

Sequeira  has  treated  forty-five  cases  of  epithelioma.  Accord- 
ing to  his  experience,  the  ulcers  heal  rapidly  and  cavities  fill 
up  in  a  remarkable  manner.  Difficulty  has  been  experienced 
with  hard  raised  edges,  and  slight  and  easily  treated  recurrences 
have  been  noticed.  In  the  treatment  of  cancer  by  this  method 
pain  is  relieved  and  the  discharge  dried  up.  In  some  cases, 
however,  the  tumors  grow  rapidly  in  spite  of  exposures. 

Seabury  Allen  has  reported  three  cases  of  epithelioma,  all 
of  which  were  cured;  the  first,  of  the  nose  and  inner  canthus 
of  the  eye;  the  second,  an  epithelioma  of  the  nose,  cheeks, 
forehead,  and  around  the  eye;  the  third,  a  rodent  ulcer. 

Beck  says,  in  commenting  upon  an  excellent  result  in  an 
epithelioma  of  the  eyelid  and  cheek,  that  he  still  regards  "ex- 

* "  The  Rontgen  Rays  in  Medicine  and  Surger}',''  pp.  420,  655.  Boston 
Med.  and  Surg.  Jour.,  1901,  cxliv,  p.  329. 

fMed.  Record,  1902,  Ixi,  p.  83.  }  Phila.  Med.  Jour.,  1902,  ix,  p.  221. 

§Med.  Record,  1902,  Ixi,  pp.  361,  801. 

||  Dominion  Med.  Monthly,  1902,  xiv,  p.  76. 

**Phila.  Med  Jour.,  1902,  ix,  p.  676. 

tfN.  Y.  State  Jour,  of  Med.,  1902,  ii,  p.  176. 

Jt  Interstate  Med.  Jour.,  1902,  ix,  p.  531. 

\\  Brit.  Med.  Jour.,  1901,  ii,  p.  853.          ||||  Brit.  Med.  Jour.,  1902,  i,  p.  265. 

*t  Brit.  Med.  Jour.,  1901,  ii,  851,  1901,  i,  p.  332. 

*JMittheil.  a.  d.  Grenzgeb.  d.  Med.  u.  Chir.,  1900,  vi,  p.  347. 

*'i  Fortschr.  a.  d.  Geb   d.  Rontgenstrahlen,  1901,  iv,  p.  145. 

*||  Arch.  f.  Derm.  u.  Syph.,  1902,  lix,  p.  421.          f*  Lancet,  1901,  ii,  p.  144. 

tt  Loc.  cit.          f?  Loc.  cit.           f||  IMC.  cit.  J*  Loc.  cit.  Jf  Loc.  cit. 

Jg  Canada  Lancet,  1902,  xxxv,  p.  526.  J||  Loc.  cit.  §*  Loc.  cit. 

§t  Loc.  cit.  gf  Loc.  cit.  g||  Buffalo  Med.  Jour.,  1901,  xl,  p.  381. 

II*  Therapeutic  Gazette.  1902.  xxvi,  p.  145. 

||t  Boston  Med.  and  Surg.  Jour.,  1902,  cxlvii,  p.  431. 


LITERATURE    OF    EPITHELIOMA.  405 

tensive  removal  as  the  proper  treatment.  The  Rontgen  rays, 
however,  should  be  considered  in  the  after-treatment." 

Duncan  has  reported  one  case  of  carcinoma  of  the  penis  in 
which  pain  and  discharge  were  stopped.  Otherwise  there  was 
no  effect. 

Sjogren  and  Sederholm  state  that  treatment  with  x-rays  is  of 
great  value  when  the  cancer  is  inoperable,  when  it  covers  a 
large  area,  or  when  patients  refuse  operation. 

Sjogren  has  reported  four  epitheliomata  successfully  treated 
which  have  had  no  recurrence  in  twelve,  nine,  eight,  and  six 
months  respectively.  Sjogren,*  in  another  article,  notes  that 
improvement  may  be  seen  before  the  appearance  of  reaction, 
but  that  in  order  to  obtain  a  cure  it  is  necessary  to  induce  a 
severe  reaction  producing  a  destruction  of  the  diseased  tissue. 

Stenbeck's  original  case  was  a  rodent  ulcer  of  nine  years' 
duration  on  the  bridge  of  the  nose  of  a  woman  seventy-two 
years  old.  The  diagnosis  in  the  case  was  made  clinically,  but 
was  confirmed  by  Professor  Berg,  of  Stockholm.  Daily  sittings 
were  given  at  the  start  of  ten  to  twelve  minutes'  duration,  with 
moderately  strong  x-rays  and  with  the  tube  at  a  distance  of 
15  to  20  cm.  After  about  forty  sittings  the  ulcer  disappeared 
with  the  formation  of  a  healthy  scar.  Stenbeck  noted  in  this 
case  the  early  disappearance  of  discharge  from  the  ulcer  under 
x-rays  and  the  greater  resistance  to  the  x-rays  offered  by  the 
nodular  borders  of  the  lesion — both  facts  which  have  been  con- 
firmed abundantly  since  that  time. 

Among  the  first  cases  reported  in  the  United  States  were 
those  of  Johnson  and  Merrill.  They  included  in  their  first 
report  three  cases  of  epithelioma  treated  by  this  method  with 
symptomatic  cures,  concerning  which  in  a  subsequent  report 
two  years  later  they  were  able  to  give  further  details.  The  first 
case,  an  epithelioma  one-half  inch  in  diameter  on  the  cheek, 
was  symptomatically  cured  in  October,  1899;  two  and  a  half 
years  later  the  original  scar  remained  soft  and  healthy.  The 
second  case  was  an  epithelioma  of  the  nose  involving  the  septum 
which  was  cured  in  the  summer  of  1900;  a  year  later  there  was 
no  evidence  of  recurrence.  The  third  case,  a  small  epithelioma 

*  Fortschr.  a.  d.  Geb.  d.  Rontgenstrahlen,  1901,  v,  p.  37. 


406  CUTANEOUS   CARCINOMA. 

on  the  tip  of  the  nose,  showed  no  sign  of  recurrence  two  years 
after  its  disappearance  under  x-rays.  They  also  reported  addi- 
tional cases,  making  a  list  of  sixteen  in  all.  Of  these  sixteen, 
ten  are  apparently  cured  and  four  show  improvement ;  of  these 
four,  three  give  promise  of  ultimate  recovery  under  further 
treatment.  Two  cases  failed  to  derive  benefit  from  treatment 
other  than  relief  from  pain  and  decrease  of  discharge. 

I  have  treated  twenty-seven  successive  cases  of  epithelioma 
in  which  the  results  are  now  sufficiently  definite  to  make  them 
of  interest  in  this  connection.* 

Case  46. — Mrs.  ,  aged  sixty-eight,  referred  to  me  by 

Dr.  John  L.  Porter,  with  the  following  history,  most  of  which 
is  taken  from  the  records  of  St.  Luke's  Hospital.  About  twenty 
years  ago  a  "wart"  appeared  in  the  right  supraclavicular  space 
and  gradually  increased  in  size.  Three  years  after  its  appear- 
ance the  surface  broke  down  and  an  ulcer  developed  which, 
after  two  years'  duration,  was  excised  by  Dr.  J.  B.  Murphy. 

The  disease  recurred  in  the  upper  angle  of  the  scar  and  en- 
larged until  1894,  when  she  came  to  St.  Luke's  Hospital.  It 
was  then  the  most  extensive  epithelioma  I  have  ever  seen, 
covering  almost  the  entire  upper  third  of  the  back,  and  extend- 
ing over  the  right  shoulder  to  the  clavicle.  I  fortunately  photo- 
graphed her  at  that  time. 

During  1894-95  she  was  in  St.  Luke's  Hospital,  in  the  services 
of  Drs.  John  E.  Owen  and  L.  L.  McArthur,  where  vigorous  at- 
tempts were  made  to  extirpate  the  diseased  tissues.  The  tumor 
was  destroyed  and  extensive  grafts  were  made,  so  that  the  disease 
area  over  the  back  was  converted  into  scar  tissue,  most  of 
which  remained  healthy.  The  disease  recurred  in  a  short  time, 
involving  the  area  over  the  right  shoulder,  from  the  spine  of  the 
scapula  behind  to  a  point  below  the  clavicle  in  front,  an  area 
covering  the  entire  upper  surface  of  the  shoulders. 

From  1894  until  1900  she  was  more  or  less  constantly  an 
out-patient  at  St.  Luke's,  and  for  the  last  two  years  it  was 

*  Several  of  these  cases  were  demonstrated  after  treatment  before  the  Chicago 
Medical  Society,  February  26,  1902,  and  Case  46  was  demonstrated  before  the 
American  Dermatological  Association  June  1,  1901.  It  may  be  added  that  my 
lupus  cases  numbers  34  and  35  were  demonstrated  before  the  American  Derma- 
tological Association,  June  1,  1901. 


4<  n 


REPORT   OF   CASES.  409 

not  thought  feasible  to  make  any  further  attempt  at  extirpation 
of  the  growth.  The  extent  of  the  growth,  at  the  time  she 
presented  herself  for  treatment  with  x-rays,  January  15,  1901, 
is  shown  in  figure  116.  As  shown  in  the  photograph,  the  disease 
involved  the  greater  part  of  the  area  over  the  right  shoulder. 
The  largest  lesion  was  situated  at  the  junction  of  the  neck 
and  shoulder,  and  consisted  of  three  confluent  ulcers,  forming 
in  all  an  ulcer  with  a  diameter  of  about  three  inches.  This 
was  a  typical  epitheliomatous  ulcer  with  elevated,  rolled,  hard, 
pearly  borders.  In  addition,  there  were  perhaps  twenty  other 
epitheliomatous  ulcers,  varying  from  the  size  of  a  finger-nail 
to  that  of  a  small  pea,  around  and  posterior  to  the  large  ulcer. 
Extending  over  the  front  of  the  shoulder  was  a  triangular  space 
with  the  apex  below  the  clavicle,  which  contained  numerous 
small  epitheliomata.  Some  of  these  were  ulcerating,  but  most 
of  them  were  intact  nodules. 

All  of  the  tissue  of  the  affected  area  was  inflamed  and  indu- 
rated. There  was  no  evidence  of  involvement  of  contiguous 
glands  or  of  the  underlying  tissue.  There  was  free  discharge 
from  the  ulcers  and  for  many  years  the  patient  had  suffered 
severe  pain.  Tissue  for  examination  was  excised  from  the  border 
of  the  large  ulcer  and  sections  of  this  tissue  presented  the  typical 
histological  picture  of  superficial  epithelioma  (Fig.  118).  The 
tissue  was  examined  for  blastomycetes,  which  were  absent. 

Through  the  courtesy  of  Dr.  Porter  I  obtained  a  section 
that  was  made  seven  years  ago.  This  section  also  showed 
characteristic  structure  of  epithelioma. 

The  patient  was  put  under  exposures  to  x-rays  on  January 
15,  1901,  and  had  almost  daily  sittings  until  February  14 — 
eighteen  in  all.  Within  a  week  the  discharge  from  the  ulcers 
almost  entirely  ceased,  and  the  patient  volunteered  the  state- 
ment that  her  shoulder  was  free  from  pain  and  that  she  was 
able  to  sleep  comfortably  for  the  first  time  in  many  years. 
After  this  first  week  there  was  practically  no  discharge  from 
the  ulcers,  and  almost  no  recurrence  of  pain.  The  disappear- 
ance of  the  discharge  was  the  more  interesting  because  before 
the  patient  came  under  treatment  with  x-rays  she  had  been  a 
regular  attendant  at  St.  Luke's  Hospital  out-patient  depart- 


410  CUTANEOUS    CARCINOMA. 

ment,  where  her  shoulder  had  been  dressed  as  often  as  neces- 
sary. 

On  February  4  the  ulcers  were  decreasing  rapidly  in  size, 
and,  what  was  more  significant,  the  rolled  edges  were  shrinking. 
On  that  date  the  patient  was  hurt  by  a  fall  and  was  not  able 
to  appear  for  further  exposures  until  March  13.  In  the  interval 
she  was  in  the  Charity  Hospital,  where,  at  my  request,  the 
physicians  kindly  saw  that  no  change  in  the  local  treatment 
was  made  from  my  application  of  boric  acid  vaselin. 

She  returned  for  treatment  on  March  13,  and  from  March  13 
to  May  4  she  had  twenty  sittings,  varying  from  daily  sittings 
to  sittings  at  intervals  of  from  four  to  five  days.  By  April 
5  the  evidences  of  epithelioma  were  limited  to  a  small  ulcer 
not  larger  than  a  little  finger-nail  at  the  site  of  the  previous 
larger  ulcer,  and  to  two  rows  of  very  characteristic  nodules 
in  the  supraclavicular  space. 

Up  to  this  time  the  exposures  had  always  been  made  so  that 
the  greatest  intensity  of  light  fell  on  the  shoulder,  and  the 
lesions  over  the  clavicle,  therefore,  had  received  less  of  the  rays. 
After  April  5  the  upper  surface  of  the  shoulder,  which  had 
been  getting  exposures  of  fifteen  minutes,  was  given  exposures 
of  five  minutes,  and  the  lesions  over  the  clavicle  were  given 
direct  exposures  of  fifteen  minutes.  Within  five  days  after 
beginning  these  exposures  over  the  nodules  in  the  supracla- 
vicular space  a  very  remarkable  change  was  noticed  in  them. 
They  began  to  shrink  and  to  disappear  rapidly.  By  April  16 — 
that  is,  after  ten  direct  exposures  of  fifteen  minutes  each — 
these  nodules  had  entirely  disappeared.  They  were  absorbed 
without  dermatitis  or  any  breaking-down.  Sittings  were  dis- 
continued on  April  16,  as  the  shoulder  showed  slight  dermatitis. 
By  April  29  this  irritation  had  entirely  disappeared.  Between 
April  29  and  May  8  the  small  ulcer  on  the  upper  surface  of 
the  shoulder,  the  last  trace  of  epithelioma,  entirely  healed.  Her 
condition  on  May  6  is  shown  by  the  photograph  (Fig.  117). 

At  the  time  of  the  first  publication  of  this  case  particular 
attention  was  called  to  the  scars,  which  were  of  the  excellent 
cosmetic  character  that  we  have  since  learned  to  expect  after 
treatment  by  x-rays.  They  were  hardly  scars  at  all;  the  skin 


Fig.  118. — Microphotograph  from  Case  46. 


411 


REPORT   OF    CASES.  413 

was  smooth  and  soft  without  contractures  or  induration,  and 
showed  hardly  any  trace  of  the  previous  ulcers.  This  patient 
had  a  few  exposures  after  May,  1901,  but  never  enough  to 
have  any  effect. 

She  died  September  23,  1902,  from  the  effects  of  an  accident. 
She  was  a  very  feeble  old  woman,  living  under  unfavorable 
circumstances,  and  six  weeks  before  her  death  fell  from  a  high 
porch  and  received  injuries  from  which  she  never  rallied.  There 
was  no  clinical  evidence  of  metastatic  carcinoma.  A  portmor- 
tem  was  not  allowed,  but  I  succeeded  in  getting  the  scar  tissue 
from  the  shoulder  at  the  point,  and  the  only  point,  which 
looked  suspicious.  There  was  an  ulcer  the  size  of  a  pea,  which 
on  examination  showed  evidences  of  carcinoma.  This  small 
lesion  could  easily  have  been  handled  by  any  of  the  ordinary 
methods  of  treatment  or  by  x-rays.  The  report  of  this  case 
on  September  28,  1901,  was  the  third  report  of  carcinoma 
healed  by  x-rays  published  in  America,  and  was  up  to  that 
time,  I  believe,  the  most  extensive  carcinoma  treated  success- 
fully by  x-rays  that  had  been  reported  anywhere.  It  was 
reported  with  great  detail  because  at  the  time  of  its  publication 
it  was  extremely  important  to  establish  the  diagnosis  beyond 
question.  The  two  reports  preceding  this  case  were  those  of 
Smith  and  of  Johnson  and  Merrill.  Smith  had  published, 
December  1,  1900,  a  case  of  rodent  ulcer  which  he  had  cured 
with  x-rays.  Johnson's  and  Merrill's  article  appeared  the  fol- 
lowing week. 

Case  47. — Mrs.  ,  aged  sixty-eight,  referred  to  me  by 

Dr.  Martin  F.  Engman,  of  St.  Louis.  The  history  of  the  case 
is  as  follows:  Twelve  years  ago  a  small  nodule  developed  upon 
the  ala  nasi,  which  ulcerated  and  was  removed,  but  soon  re- 
curred. In  the  last  ten  years  the  lesion  has  been  treated  by 
almost  every  plan  short  of  complete  ablation  of  the  nose,  but 
always  with  prompt  recurrence.  In  the  summer  of  1900  she 
consulted  Dr.  Frank  Hartley,  of  New  York,  who  advised  a  plastic 
operation,  but  she  declined  further  operative  procedures. 

The  condition  at  the  time  she  began  treatment  with  x-rays 
is  indicated  in  figure  119.  There  was  an  ulcer  occupying  almost 
the  entire  right  ala  nasi  and  spreading  down  on  the  cheek, 


414  CUTANEOUS   CARCINOMA. 

a  similar  small  ulcer  was  on  the  left  ala,  and  between  the  two 
was  an  area  of  scar  tissue,  the  result  of  previous  treatment. 
The  ulcers  were  typical  epitheliomata  in  appearance ;  deep,  with 
rolled,  pearly  borders,  and  fed  by  numerous  dilated  capillaries. 
The  disease  was  evident  within  the  nostrils  and  the  walls  of 
the  nostrils  were  of  almost  papery  thinness.  The  septum  was 
involved  and  probably  also  the  nasal  bones.  The  ulcers  bled 
frequently  and  profusely  and  were  the  source  of  much  pain. 
Altogether  the  case  seemed,  both  to  Dr.  Engman  and  to  me, 
to  present  as  unfavorable  conditions  for  cure  as  possible. 

She  was  put  under  daily  exposures  to  x-rays  April  26,  1901. 
By  the  tenth  of  May  the  borders  of  the  ulcers  were  shrinking, 
some  healthy  epithelium  was  beginning  to  grow  out  from  the 
edges,  and  the  discharge  was  greatly  lessened.  By  June  5  the 
ulcer  on  the  left  side  of  the  nose  was  healed  with  a  healthy 
looking  scar.  By  the  middle  of  June  the  ulcer  on  the  right 
side  of  the  nose  was  reduced  to  the  size  of  a  wheat-grain.  This 
lesion  at  the  point  where  the  ala  nasi  was  perforated  was  slow 
to  heal,  and  the  treatments  were  carried  to  the  point  of  pro- 
ducing acute  dermatitis,  so  that  by  August  8  the  exposures 
were  stopped  on  this  account.  After  stopping  the  exposures 
the  dermatitis  increased  until  the  exposed  surface  was  denuded 
of  epidermis.  This  healed  in  about  ten  days,  and  at  the  same 
time  the  last  trace  of  the  ulcer  on  the  right  side  disappeared. 
In  December,  1901,  I  asked  Dr.  T.  Melville  Hardie,  of  the  Uni- 
versity of  Illinois,  to  examine  her,  and  he  kindly  gave  me  the 
following  report': 

"The  general  appearance  of  the  mucous  membrane  covering 
the  septum  and  the  external  wall  of  the  nostril  is  that  charac- 
teristic of  atrophic  rhinitis.  The  membrane  is  in  nearly  every 
place  thinner  than  normal  and  there  are  numerous  spots  where 
there  is  present  a  slight  dried  oozing  of  blood,  which  follows 
the  removal  of  the  crusts  of  dried  mucus.  This  condition  is 
more  obvious  in  the  right  nostril,  but  this  is  the  case  partly 
because  of  the  partial  obstruction  in  the  left  nostril  caused 
by  a  deflection  and  ridge  of  the  septum. 

"The  right  inferior  turbinated  bone  is  smaller  than  normal, 
the  atrophy  having  extended  to  the  bone,  besides  affecting  the 


S-. 


415 


REPORT   OF    CASES.  417 

mucous  membrane  covering  it.  The  anterior  end  of  the  middle 
turbinated  body  is  enlarged  and  the  mucous  membrane  covering 
it  is  atrophic.  Careful  examination  discloses  no  ulceration  in 
the  nostril  and  no  infiltration,  the  only  irregular  feature  of  the 
diseased  portion  being  the  over-red  color  of  the  mucous  mem- 
brane of  the  floor  and  the  inferior  turbinated  body.  The  naso- 
pharynx also  exhibits  atrophy  of  its  mucous  membrane  and 
bleeds  when  the  crusts  of  dried  mucus  are  forcibly  disturbed." 

All  of  the  scar  tissue  has  remained  healthy,  and  the  only 
trace  of  disease  that  has  reappeared  was  a  little  mass  the  size 
of  a  pea  that  gradually  developed  above  the  scar  half  an  inch 
below  the  inner  canthus  of  the  right  eye.  This  was  very  hard 
and  attached  to  the  periosteum.  It  was  removed  on  my  advice 
in  October,  1902,  and  was  found  to  contain  some  carcinomatous 
tissue.  The  condition  at  present  is  shown  in  figure  120.  The 
result  in  this  case  may  be  regarded,  I  believe,  with  entire  satis- 
faction in  spite  of  the  small  recurrence.  Without  x-rays  the 
chance  of  relief  was  very  remote  and  possible  only  at  the  expense 
of  a  disfiguring  operation.  With  x-rays  the  nose  has  been  saved 
and  the  only  operation  necessary  reduced  to  one  of  minor 
character. 

Case  48. — Healthy  man,  aged  thirty-eight.  In  November  or 
December,  1900,  there  appeared  on  his  nose  at  the  site  of  a 
previous  wart  an  indurated  nodule  which  ulcerated  and  spread 
rapidly.  In  May,  1901,  he  came  to  my  clinic  at  the  College  of 
Physicians  and  Surgeons.  The  condition  at  that  time  is  shown 
in  figure  121.  There  was  an  ulcer  involving  the  tip  of  the  nose 
the  size  of  a  five-cent-piece.  Sections  taken  from  the  borders 
of  the  ulcer  confirmed  the  diagnosis  of  epithelioma  (Fig.  123). 
It  was  an  epithelioma  situated  deep  in  the  subcutaneous 
tissue,  showing  many  pearls  and  growing  rapidly. 

He  was  put  under  x-ray  treatment  May  23,  1901,  and  was 
given  exposures  more  or  less  regularly  for  two  and  a  half  months. 
There  was  a  healthy  scar  by  September  15.  His  condition  at 
that  time  and  at  present  is  shown  in  figure  122. 

Case  49. — Healthy  man,  aged  seventy-three,  referred  to  me 
November  5,  1901,  from  the  Illinois  Eye  and  Ear  Infirmary, 
for  treatment  of  the  ulcer  shown  in  figure  124.  This  was  a 

27 


418  CUTANEOUS   CARCINOMA. 

sharply  punched-out  ulcer  in  the  right  nasal  furrow  the  size  of 
a  little  finger-nail,  with  raised,  waxy  borders  and  profuse  blood- 
supply,  and  painful.  The  disease  began  about  two  years  ago 
in  a  warty  growth,  which  bled  easily.  I  got  no  section  of  it, 
but  it  was  in  appearance  a  typical  epithelioma,  and  there  is 
no  doubt  of  the  diagnosis.  The  result  after  three  months' 
treatment  is  shown  in  figure  125.  There  is  a  smooth,  soft,  white, 
healthy  looking  scar,  without  induration. 

Case  50. — Man,  aged  seventy-five,  referred  to  me  by  Dr. 
Xorval  H.  Pierce,  Surgeon  to  Illinois  Eye  and  Ear  Infirmary, 
with  an  epithelioma  of  eleven  years'  duration.  It  involved  the 
auditory  canal  for  its  external  one-third,  and  the  entire  inner 
surface  of  the  concha,  and  had  spread  for  half  an  inch  upon  the 
cheek,  the  tragus  having  been  destroyed.  He  was  put  under 
x  -ray  exposures  November  5  and  treated  daily  to  December  5, 

1901,  when  some  erythema  developed  and  the  ulcer  began  to 
heal.     The  sittings  were  nevertheless  continued  to  January  25, 

1902,  when  there  developed  marked   congestion  and  later  a 
superficial  burn  of  the  exposed  area.    This  gradually  subsided, 
and  with  its  subsidence  the  ulcer  healed.     Since  April,  1902, 
the  entire  site  of  the  epithelioma  has  been  covered  with  healthy 
skin.     In  September,   1902,  a  small  nodule  appeared  in  the 
concha;  I  destroyed  this  successfully  with  Bougard's  paste  and 
a  healthy  scar  quickly  formed. 

Case  51. — Mrs.  -  — ,  aged  sixty-one,  referred  to  me  by  Dr. 
M.  F.  Engman,  of  St.  Louis.  About  twelve  years  ago  a  lesion 
developed  on  her  forehead  above  the  right  eye  which  was 
recognized  as  an  epithelioma.  Two  years  ago  it  had  developed 
into  an  ulcer  the  size  of  a  half-dollar,  and  in  November,  1899, 
she  went  to  Dr.  William  T.  Bull,  of  New  York  city.  Dr.  Bull 
has  kindly  given  me  his  memoranda  of  the  case,  as  follows: 
''Circular  ulcer  of  forehead  in  center  and  reaching  to  eyebrows 
as  large  as  fifty-cent-piece.  Edges  slightly  elevated  and  hardly 
movable.  This  appeared  first  ten  years  ago  as  an  indurated 
nodule  and  was  destroyed  by  caustics.  It  reappeared  and  was 
cut  out  three  times — the  last  time  four  years  ago.  At  operation 
[Dr.  Bull's]  the  ulcer,  with  a  wide  margin  of  skin,  was  removed 
and  the  raw  surface  covered  with  four  skin-grafts.  Healing  was 


419 


Fig.  123. — Microphotograph  from  Case  48. 


421 


423 


REPORT    OF   CASES.  425 

complete  in  three  weeks.  Dr.  Dunton  examined  the  tissue  re- 
moved and  pronounced  the  growth  an  epithelioma. "  After  Dr. 
Bull's  operation  the  scar  remained  healthy  until  September, 
1901,  when  two  small  ulcers  developed  in  the  border  of  the 
scar. 

When  she  came  under  my  care,  November  14,  1901,  there 
was  on  the  forehead,  above  the  left  eyebrow,  a  healthy  looking 
scar  2  by  2  inches.  On  the  external  border  of  the  scar  there 
were  two  small  ulcers,  one  at  the  upper  outer  angle  the  size 
of  a  little  finger-nail,  the  other  at  the  lower  outer  angle  some- 
what smaller,  presenting  the  picture  of  typical  small  epithe- 
liomata.  The  upper  half  of  the  inner  border  of  the  scar  was 
occupied  by  a  red  indurated  scaly  patch  an  inch  long  by  half 
an  inch  broad,  around  which  were  numerous  dilated  capillaries. 
This  presented  the  picture  of  an  inflamed  patch  of  senile  kera- 
tosis  undergoing  degeneration  into  epithelioma. 

She  was  given  exposures  daily  over  the  patch  and  over  the 
ulcers  until  the  lesions  became  somewhat  inflamed,  and  after- 
ward the  dermatitis  was  kept  at  this  stage.  By  December  8, 
1901, — approximately  a  month, — the  ulcers  were  healed,  and 
by  January  8 — two  months — the  induration  had  entirely  dis- 
appeared. The  skin  at  the  site  of  the  ulcers  is  smooth,  per- 
fectly soft,  and  free  from  induration.  The  site  of  the  patch 
of  verruca  senilis  on  the  inner  border  of  the  scar  is  still  slightly 
red  as  a  result  of  the  exposures,  but  it  is  smooth  and  soft  and 
the  induration  has  entirely  disappeared.  There  has  been  no 
recurrence. 

Case  52. — Mrs. ,  aged  fifty,  with  an  epithelioma  of 

five  years'  duration  as  shown  in  photograph  (Fig.  126).  The 
disease  involved  an  area  on  the  side  of  the  nose  and  around 
the  inner  canthus  as  large  as  a  fifty-cent-piece.  There  were  two 
ulcers  in  the  area,  one  the  size  of  a  finger-nail  on  the  side  of 
the  nose,  the  other  half  that  size  at  the  inner  canthus.  The 
ulcers  were  sharply  excavated,  with  elevated,  rolled,  nodular 
borders,  and  around  them  the  tissue  was  indurated  and  waxy 
looking.  It  was  a  typical  small  rodent  ulcer,  such  as  is  often 
seen  in  this  location,  but  no  tissue  was  gotten  for  examination. 
The  result  March  1,  1902,  after  two  months  of  treatment,  is 


426  CUTANEOUS    CARCINOMA. 

shown  in  figure  127.  There  is  practically  no  scarring;  the  skin 
is  white  and  smooth  and  there  is  no  induration.  It  would  be 
hard  to  say  that  any  ulcer  had  existed.  The  case  illustrates 
the  ease  with  which  lesions  about  the  eye  can  be  treated  with 
x-rays. 

Case  53. — Spare-built  man,  aged  thirty-five,  referred  to  me 
by  Dr.  T.  J.  Knudson,  from  St.  Luke's  Hospital.  Eleven  years 
ago  a  small  nodule  appeared  on  the  right  cheek,  below  the 
eye,  which  gradually  increased  in  size  and  after  two  years 
ulcerated.  The  lesion  was  treated  from  time  to  time  by  different 
surgeons  in  various  parts  of  the  United  States.  Four  years  ago 
he  was  admitted  to  Cook  County  Hospital  in  the  service  of 
Dr.  T.  A.  Davis.  Dr.  Davis  did  a  radical  operation,  removing 
the  ulcer  and  a  large  amount  of  the  surrounding  tissue  and 
restoring  the  lower  lid  by  an  extensive  plastic  operation.  At 
the  end  of  a  year  the  disease  recurred  in  the  scar  and  rapidly 
enlarged,  involving  the  orbit.  During  the  winter  of  1899-1900 
he  was  in  the  Cook  County  Hospital  in  the  service  of  Dr.  Charles 
Adams.  The  disease  had  then  attained  such  an  extent  that  a 
radical  operation  was  not  undertaken. 

When  he  came  to  me,  the  disease  involved  the  entire  orbit, 
the  upper  and  lower  lids,  the  side  of  the  nose,  and  the  cheek. 
A  shrunken  atrophic  globe  remained,  which  was  retracted  deep 
in  the  orbit.  Before  undertaking  treatment  by  x-rays  Dr.  W.  H. 
Wilder  at  my  request  removed  the  eye  on  December  5.  Xo 
attempt  was  made  to  destroy  the  carcinoma  in  this  operation, 
and  on  December  14,  1901,  he  returned  for  x-ray  exposures. 
The  accompanying  photograph  (Fig.  128)  does  not  adequately 
show  the  condition  at  that  time.  A  microphotograph  of  a 
section  of  the  tissue  taken  from  the  lower  lid  two  weeks  later  is 
shown  in  figure  93,  page  267,  and  confirms  the  diagnosis  of  epi- 
thelioma.  At  this  time  the  patient  was  suffering  exquisite  pain, 
which  had  not  been  relieved  by  removing  the  eye,  and  from 
anxiety,  pain,  and  loss  of  sleep  his  physical  condition  was  greatly 
reduced.  He  was  put  under  x-ray  treatment  December  14,  and 
had  almost  daily  sittings  to  January  27,  1902.  The  exposures 
were  carried  to  the  point  of  producing  erythema  and  slight  des- 
quamation,  but  no  weeping.  Within  a  week  after  beginning 


427 


Fig.  128. — Carcinoma  of  the  orbit. 


Fig.  129. 


429 


REPORT  OF   CASES.  431 

the  treatment  his  pain  had  ceased  and  the  discharge  began  to 
diminish.  After  that  time  the  improvement  was  continuous. 
The  borders  and  the  nodules  gradually  shrank  and  the  ulcers 
became  smaller  and  finally  healed  over.  The  condition  just 
before  healing  became  complete  is  shown  in  figure  129.  The 
patient  was  free  from  pain  practically  from  the  beginning  of 
the  treatment  and  entirely  regained  his  health  and  spirits. 
March  1,  1902,  this  patient  disappeared,  and  was  not  seen 
again  until  August  6,  1902,  when  he  appeared  with  a  round 
ulcer  at  the  inner  angle  of  the  eye  f  of  an  inch  deep  and  half 
an  inch  in  diameter.  This  has  been  vigorously  exposed  and  is 
now  greatly  improved. 

Case  54. — Woman,  aged  forty,  with  a  superficial  epithelioma 
on  the  cheek  an  inch  below  the  right  eye.  The  lesion  had 
appeared  three  years  before  and  gradually  enlarged.  At  the 
time  she  came  under  treatment  there  was  a  superficial  lesion 
the  size  of  a  thumb-nail,  consisting  of  scar  tissue  resulting  from 
previous  application  of  caustics  and  a  periphery  of  indurated 
nodules  supplied  by  numerous  dilated  blood-vessels.  She  re- 
ceived twelve  x-ray  exposures  between  February  24  and  March 
8,  1902,  each  at  a  distance  of  5  cm.  and  of  fifteen  minutes' 
duration.  On  March  8  an  acute  dermatitis  developed,  which 
disappeared  by  March  31.  With  its  disappearance  all  of  the 
nodules  entirely  disappeared.  Eight  months  later  the  scar 
remained  smooth  and  healthy. 

Case  55. — Man,  aged  forty-one,  referred  to  me  by  Dr.  Edmund 
Pinchon,  of  Chicago,  with  an  epithelioma  on  the  tip  and  ala 
of  the  nose  an  inch  in  diameter.  It  began  in  1883  as  an  indu- 
rated nodule,  which  soon  formed  a  small  ulcer.  This  grew  very 
slowly  and  in  1893  had  reached  one-half  inch  in  diameter.  It 
was  then  cauterized,  and  healed,  but  recurred  in  about  a  year. 
The  second  ulcer  was  excised  by  Dr.  Christian  Fenger,  and 
after  nine  months  recurred.  At  the  time  of  coming  under 
observation  there  was  an  ulcer  about  half  an  inch  in  diameter 
with  rolled  indurated  edges  situated  on  the  left  ala  nasi.  The 
diagnosis  of  carcinoma  was  confirmed  microscopically.  The 
ulcer  was  situated  at  the  border  of  a  scar  about  an  inch  in 
diameter  occupying  the  entire  tip  of  the  nose,  the  result  of  the 


432  CUTANEOUS    CARCINOMA. 

previous  operation.  The  area  was  given  thirteen  exposures  at  a 
distance  of  5  cm.  and  of  fifteen  minutes'  duration  each  between 
March  12  and  April  25,  1902.  On  April  14,  before  the  develop- 
ment of  any  marked  erythema,  the  ulcer  had  healed  with  a 
healthy  scar,  and  eight  months  later  remains  well. 

Case  56. — Woman,  aged  sixty-five,  with  an  epithelioma  the 
size  of  a  split  pea  on  the  forehead.  This  was  exposed  to  x-rays 
to  the  point  of  producing  an  acute  dry  dermatitis,  with  the 
disappearance  of  which  the  lesion  disappeared  leaving  an  almost 
imperceptible  white  scar.  This  case  has  been  well  since  March 
29,  1902,  eight  months. 

Case  57. — Man,  aged  forty-five,  referred  to  me  by  Dr.  C.  D. 
Westcott,  of  Chicago.  Three  years  ago  a  mole  about  the  size 
of  half  a  wheat-grain,  which  he  had  always  had  on  the  lower 
left  eyelid,  became  indurated  and  then  ulcerated,  and  in  spite 
of  treatment  upon  several  occasions  with  caustic  pastes  gradually 
increased.  At  the  time  that  he  came  under  my  care  the  disease 
had  spread  until  it  involved  the  entire  lid.  The  palpebral  border 
was  destroyed  throughout  its  full  extent,  and  along  the  line  of 
juncture  between  the  skin  and  the  mucous  membrane  there 
was  a  string  of  characteristic  hard  waxy  nodules.  There  were 
several  tubercles  also  involving  the  juncture  of  the  mucous 
membrane  and  conjunctiva,  so  that  the  distance  of  the  cornea 
from  the  nearest  nodules  was  very  short.  In  this  case  great 
care  was  taken  in  giving  the  exposures  to  avoid  striking  the 
eye.  A  mask  was  made  to  cover  the  whole  face  and  shaped 
to  the  curve  of  the  eye  with  a  crescent-shaped  opening  in  it 
to  correspond  to  the  area  to  be  exposed.  The  diseased  border 
was  pulled  as  far  down  as  possible,  but  owing  to  the  attachment 
to  the  conjunctiva  this  manoeuvre  was  of  little  effect.  The  ex- 
posures were  also  given  slightly  from  above  to  avoid  striking 
the  conjunctiva.  Between  April  3  and  May  7,  1902,  he  received 
thirty  exposures  at  an  average  distance  of  8  cm.  and  of  an 
average  length  of  seven  and  a  half  minutes.  On  May  7  it  was 
noted  that  "there  is  some  irritation  of  the  lower  lid,  but  no 
conjunctivitis.  Nodules  shrinking."  On  May  16  I  made  a 
further  note:  "Irritation  practically  gone.  Nodules  on  lower 
lid  considerably  smaller."  On  May  16  exposures  of  similar 


REPORT  OF   CASES.  433 

length  and  intensity  were  renewed  and  given  daily  until  May 
31,  when,  on  account  of  slight  conjunctivitis,  they  were  stopped. 
This  conjunctivitis  was  very  slight  and  rapidly  disappeared, 
and  the  exposures  were  renewed  on  June  9  and  given  daily 
until  July  2.  On  July  2  the  lid  became  red  and  congested 
and  exposure  was  stopped.  The  lower  quadrant  of  the  con- 
junctiva was  slightly  injected  up  to  the  edge  of  the  cornea. 
By  this  time  the  border  of  the  lid  was  perfectly  soft  and  free 
from  induration.  After  that  date  he  had  no  further  exposures. 
The  irritation  quickly  subsided  and  left  a  smooth,  soft,  healthy 
looking  lid. 

Case  58. — Mrs. ,  aged  sixty.     Thirty  years  ago  a  small 

indurated  nodule  developed  on  the  cheek  an  inch  below  the  inner 
canthus  of  the  right  eye.  The  growth  gradually  increased  and 
eight  years  ago  ulcerated.  Since  that  time  it  has  been  treated 
repeatedly  with  caustics,  the  last  treatment  of  this  sort  being  a 
year  and  a  half  ago,  when  it  was  removed  by  caustics  and 
promptly  returned.  At  the  time  that  she  came  to  me  there 
was  a  large  epithelioma  involving  the  cheek,  the  side  of  the 
nose,  and  the  inner  canthus  of  the  right  eye.  The  condition 
four  weeks  after  the  beginning  of  treatment,  when  most  of  the 
ulcer  had  healed,  is  indicated  in  figure  130.  At  the  time  of 
beginning  treatment  there  was  an  ulcer  with  hard  nodular 
borders  an  inch  and  a  half  in  vertical  diameter  and  three- 
fourths  of  an  inch  in  transverse  diameter.  The  upper  and 
lower  lids  each  had  pea-sized  nodules  on  the  inner  surface. 
Exposures  were  begun  on  April  16,  1902,  and  between  that 
date  and  July  23  she  received  forty  exposures  at  an  average 
distance  of  5  cm.  and  of  five  minutes'  duration.  Great  care  was 
exercised  in  exposing  the  nodules  on  the  lids  and  avoiding  at 
the  same  time  the  cornea.  On  April  29  an  acute  dry  dermatitis 
developed.  The  following  memoranda  made  at  the  times  indi- 
cated show  the  subsequent  course  of  the  disease:  "May  7:  Ir- 
ritation subsiding  slowly.  Healing.  Lower  eyelid  slightly 
inflamed  and  puffy."  " May  17:  Irritation  gone"  (no  exposures 
having  been  given  since  April  29).  Once  subsequently  derma- 
titis was  produced,  and  this  was  followed  by  rapid  decrease 
in  the  growth.  On  July  23  treatment  was  discontinued.  The 

28 


434  CUTANEOUS    CARCINOMA. 

condition  at  that  time  is  shown  in  figure  131.  The  scar  was 
smooth  and  healthy  looking.  On  the  edge  of  the  lid  near  the 
angle  of  the  eye  there  was  a  point  still  slightly  indurated.  A 
small  tubercle  developed  there  October  1,  1902,  which  disap- 
peared promptly  under  exposures.  The  entire  scar  had  a  per- 
fectly healthy  appearance. 

Case  59. — Woman,  aged  sixty-four,  referred  to  me  by  Dr.  E. 
W.  Marquardt,  of  Chicago.  Fifteen  years  ago  an  ulcer  began 
on  the  forehead,  which  gradually  spread  until  at  the  time  of 
coming  under  my  care  it  was  of  the  extent  shown  in  figure 
132.  It  occupied  the  entire  forehead,  spread  down  over  the 
upper  two-thirds  of  the  nose,  involved  both  eyebrows,  half  of 
the  right  upper  lid,  and  the  entire  left  upper  lid.  It  also  in- 
volved the  inner  canthus  of  the  right  eye,  both  canthi  of  the 
left  eye,  and  about  half  of  the  left  lower  lid.  The  left  upper 
lid  was  very  much  thickened  and  indurated,  so  that  the  eye 
had  been  closed  for  over  two  years.  The  diagnosis  of  carcinoma 
was  confirmed  by  microscopic  examination.  This  patient  re- 
ceived forty  exposures  between  May  1  and  July  1,  1902,  at 
an  average  distance  of  10  cm.  and  of  an  average  duration  of 
ten  minutes.  The  ulcer  began  to  show  improvement  promptly. 
On  June  21  the  memorandum  was  made  that  the  "ulcer  has 
been  showing  great  improvement;  healing  at  edges  for  more  than 
a  week  past."  The  condition  on  June  7  is  shown  in  figure  133. 
From  this  time  on  the  improvement  was  gradual.  On  July  10 
exposures  were  discontinued  because  of  the  development  of  a 
severe  conjunctivitis  in  the  left  eye,  which,  on  account  of  a 
disappearance  of  induration  in  the  upper  lid,  could  now  be 
opened.  She  received  no  more  exposures  until  August  25.  In 
the  mean  time  the  improvement  in  the  disease  continued,  so 
that  by  August  25  there  was  no  disease  left  except  a  small 
ulcer  on  the  center  of  the  forehead  about  an  inch  long  and 
an  inch  and  a  half  wide,  which  presented  none  of  the  appearances 
of  a  carcinoma.  Since  August  25  she  has  had  occasional  ex- 
posures over  the  forehead.  The  small  ulcer  healed  in  October, 
and  with  its  disappearance  the  last  evidence  of  the  disease 
vanished.  The  condition  March,  1903,  is  shown  in  figure  134. 

At  present  the  entire  area  is   covered  with  smooth,  white, 


435 


Fig.  132. — Cutaneous  carcinoma. 


Fig.  133. 


438 


Fig.  134 


439 


REPORT  OF   CASES.  441 

healthy  looking  skin.  The  skin  of  the  lids  and  nose  is  in  color 
and  pliability  like  the  skin  of  a  young  person.  There  is  no 
contraction  such  as  would  be  expected  in  scar  tissue.  The  eye- 
lids are  perfectly  pliable  and  as  freely  movable  as  normal  lids. 
The  loss  of  the  eye  in  this  case  is  possibly  attributable  to  a 
conjunctivitis  due  to  x-rays,  but  is  probably  not.  It  must  be 
remembered  that  this  eye  had  been  bathed  in  pus  for  a  long 
time  and  had  a  chronic  conjunctivitis  with  scars  on  the  cornea, 
and  it  is  entirely  possible  that  the  acute  inflammation  of  the 
eye  that  destroyed  the  cornea  was  due  to  infection  that  occurred 
after  she  became  able  to  open  the  eye.  Even  granting  that  the 
loss  of  the  eye  was  due  to  x-rays,  it  militates  little  against  the 
excellence  of  the  result.  The  eye  had  already  been  out  of  use 
for  two  years,  and  would  certainly  soon  have  been  destroyed 
by  the  carcinoma  had  it  not  been  checked.  The  disease  had 
gotten  beyond  the  point  of  treatment  by  any  other  method, 
unless  both  eyes  were  to  be  sacrificed. 

Case  60. — Man,  aged  sixty-five,  with  a  superficial  epitheli- 
oma  on  the  left  cheek  in  front  of  the  ear.  The  lesion  was 
triangular  in  shape,  a  little  larger  than  a  fifty-cent-piece,  and  con- 
sisted of  scar  tissue  the  result  of  previous  operations,  of  indu- 
rated nodules,  and  of  several  superficial  ulcers.  It  began  eight 
years  ago  in  front  of  the  ear  and  had  progressed  very  slowly. 
The  diagnosis  of  carcinoma  was  confirmed  microscopically.  The 
patient  was  given  fifteen  exposures  in  three  weeks  with  the 
production  of  an  acute  dry  dermatitis  on  May  24,  1902.  The 
patient  then  went  to  his  home  and  was  put  under  the  care  of 
Dr.  S.  B.  Childs,  of  Denver.  One  month  later  Dr.  Childs  wrote 
me  that  the  large  area  had  been  healed  for  several  days  and 
that  "there  are  only  two  very  small  nodules  about  the  small 
area."  The  case  has  been  subsequently  treated  by  Dr.  Childs, 
and  there  has  been  a  healthy  scar  since  July  1,  1902. 

Case  61. — Man,  aged  fifty-seven,  referred  to  me  by  Dr.  H.  H. 
Powell,  of  Cleveland,  Ohio.  The  condition  at  the  time  of  begin- 
ning treatment  is  shown  in  figure  135.  There  was  a  hard  raised 
tumor  one  and  a  half  inches  in  diameter  and  a  fourth  of  an 
inch  high  occupying  the  glabella.  It  began  several  years  before 
m  a  small  nodule  on  the  forehead,  but  had  grown  rapidly  only 


442  CUTANEOUS   CARCINOMA. 

within  the  last  year.  The  diagnosis  of  carcinoma  was  con- 
firmed microscopically.  This  patient  received  27  treatments 
between  June  7  and  July  25,  1902,  without  at  any  time  the 
production  of  a  perceptible  reaction.  Very  soon  after  beginning 
exposures  the  tumor  began  to  shrink,  and  just  one  month  after- 
ward I  made  the  memorandum:  "Carcinoma  nodules  have 
shrunken  so  that  the  surface  is  flat.  It  has  healed  over  with 
healthy  scar  tissue  except  for  an  area  about  the  size  of  a  finger- 
nail, which  shows  a  healthy  granulating  surface."  Six  weeks 
after  beginning  treatment  it  was  entirely  healed,  with  a  soft 
white  smooth  scar.  The  condition  since  July  25,  1902,  is  shown 
in  figure  136. 

This  case  is  illustrative  of  the  type  of  epithelioma  which 
is  most  susceptible  to  the  effect  of  x-rays.  A  tumor  mass 
three-eighths  of  an  inch  thick  or  more  and  one  and  a  half  inches 
in  diameter  simply  melted  away  and  was  replaced  by  healthy 
skin,  without  at  any  time  the  production  of  any  pigmentation 
or  any  erythema.  Were  there  no  other  similar  results,  this 
one  case  would  be  sufficient  to  disprove  the  statement  that 
an  x-ray  burn  must  be  produced  in  order  to  get  rid  of  carcin- 
omatous  tissue.  The  case  shows  an  ideal  reaction  to  x-rays — 
a  reaction  sufficient  to  cause  degeneration  and  disappearance 
of  the  diseased  tissue  without  any  damage  to  the  healthy  tissue 
involved  in  the  lesion.  The  result  of  the  disappearance  of  the 
carcinomatous  tissue  without  destruction  of  the  healthy  stroma 
is  shown  in  the  small  amount  of  scarring.  Less  scarring  with 
the  destruction  of  a  lesion  of  this  extent  could  hardly  be  possible. 

Case  62. — Man,  aged  sixty-five,  with  an  epithelioma  of  several 
years'  duration  the  size  of  a  finger-nail  in  the  right  nasal  furrow. 
The  patient  was  a  physician  and  the  diagnosis  of  epithelioma 
had  been  made  by  numerous  physicians.  This  patient  had  nine 
daily  exposures  between  June  24  and  July  3,  1902,  with  the 
tube  at  a  distance  of  3  cm.  from  the  surface  and  of  an  average 
duration  of  twelve  minutes.  Five  days  after  the  exposures  were 
discontinued  a  dermatitis  appeared,  which  became  quite  acute 
one  week  later,  and  then  began  to  subside.  In  two  weeks  more 
it  had  entirely  disappeared,  and  four  weeks  after  discontinuing 
the  treatment  all  of  the  induration  had  disappeared,  and  a 


Fig.  135. — Cutaneous  carcinoma. 


Fig.  136. 


443 


REPORT    OF    CASES.  445 

healthy  scar  had  formed.  The  erythema  did  not  entirely  fade 
out  for  two  months.  At  the  present  time — seven  months  later — 
there  is  a  healthy,  small,  inconspicuous  scar. 

Case  63. — Man,  aged  thirty-two,  referred  to  me  by  Dr.  Mc- 
Gregor, of  Central  Lake,  Mich.  In  July,  1900,  he  noticed  a 
warty  growth  on  the  prepuce  which  gradually  enlarged  and 
grew  very  painful.  In  February,  1902,  the  prepuce  was  removed 
by  Professor  Nancrede,  of  the  University  of  Michigan.  The 
disease  promptly  recurred,  and  he  was  then  treated  by  plasters 
without  result.  At  the  time  that  he  was  referred  to  me  there 
was  a  fungating  growth  the  size  of  a  five -cent-piece  on  the 
right  side  of  the  glans  and  prepuce.  On  the  left  side  there  was 
a  similar  lesion  on  the  glans  and  prepuce,  following  the  curve 
of  the  corona,  an  inch  long  and  five-eighths  of  an  inch  broad. 
These  masses  were  hard  and  indurated  and  in  places  ulcerating. 
The  diagnosis  of  carcinoma  was  confirmed  microscopically.  The 
inguinal  glands  were  just  palpable.  Exposures  at  a  distance  of 
5  cm.  and  of  an  average  duration  of  eight  minutes  were  begun 
over  both  masses  on  July  8,  1902,  and  were  continued  daily 
until  July  31,  with  the  production  of  a  slight  dermatitis  on 
several  occasions. 

Exposures  were  stopped  July  31  on  account  of  a  dermatitis 
which  remained  until  there  was  a  superficial  necrotic  membrane 
over  the  area  exposed.  This  gradually  healed  and  epidermis 
had  formed  over  the  area  by  September  15.  Under  the  influence 
of  the  burns  the  lesions  gradually  shrank  away,  until  by  October 
1  they  had  entirely  disappeared.  There  was  practically  no 
scarring.  The  contour  of  the  parts  was  normal  and  there  were 
no  suspicious  points.  During  the  time  of  treatment  he  also 
received  exposures  over  the  inguinal  regions.  He  has  been 
symptomatically  well  since  October  1,  1902. 

Case  64. — Man,  aged  sixty-seven,  with  an  ulcerating  epithe- 
lioma  the  size  of  a  twenty-five-cent-piece  on  the  left  cheek,  as 
shown  in  figure  137.  This  began  in  a  patch  of  senile  keratosis 
four  years  before.  When  the  ulcer  first  formed,  it  was  the  size 
of  a  finger-nail,  and  gradually  increased.  The  diagnosis  of 
carcinoma  was  confirmed  by  microscopic  examination.  This 
case  was  cured  by  fifteen  x-ray  exposures  between  July  12  and 


446  CUTANEOUS   CARCINOMA. 

August  15,  1902  (Fig.  138).  This  case  is  further  considered 
under  Senile  Keratosis,  page  566. 

Case  65. — Woman,  aged  sixty-five,  referred  to  me  by  Dr.  Geo. 
W.  Newton,  of  Chicago,  with  an  epithelioma  the  size  of  a  finger- 
nail on  the  tip  of  the  nose,  of  two  years'  duration.  The  lesion 
at  the  time  of  beginning  treatment  consisted  of  two  small  ulcers 
surrounded  by  typical  indurated  pearly  borders.  Between  July 
12  and  July  31,  1902,  she  received  thirteen  exposures  at  a  dis- 
tance of  5  cm.  and  of  an  average  length  of  twelve  and  one-half 
minutes.  August  1  dermatitis  developed,  which  became  a 
bright  red  at  the  end  of  a  week,  remained  stationary  for  another 
week,  and  then  rapidly  subsided.  With  its  subsidence  the  lesion 
disappeared,  and  on  August  27  was  replaced  by  a  smooth, 
healthy,  almost  invisible  scar. 

Case  66. — Man,  aged  sixty-seven,  referred  to  me  by  Dr. 
Rickey,  of  Grey's  Lake,  111.,  with  an  epithelioma  on  the  bridge 
of  the  nose,  one  and  a  half  inches  long  and  three-fourths  of  an 
inch  broad,  of  four  years'  duration  (Fig.  139).  This  lesion  was 
given  sixteen  exposures  between  July  17  and  August  29,  1902, 
with  the  development  of  a  slight  dermatitis.  The  lesion  began 
to  decrease  rapidly  in  size  on  August  14,  and  by  September  1 
was  replaced  by  a  smooth  healthy  scar  (Fig.  140).  This  case  is 
considered  further  under  Senile  Keratosis,  page  566. 

Case  67. — Woman,  aged  seventy,  referred  to  me  by  Prof. 
William  E.  Quine,  of  the  University  of  Illinois.  Fifteen  years 
ago  a  small  nodule  developed  on  the  cheek,  which  was  removed 
thirteen  years  ago  by  Dr.  Edmund  Andrews.  It  recurred 
promptly  and  gradually  increased  in  size.  At  the  time  that  she 
was  referred  to  me  there  was  an  epithelioma  the  size  of  a  fifty 
cent-piece  on  the  nose  and  cheek  below  the  left  eye.  The  borders 
were  raised  and  indurated,  but  there  was  little  ulceration.  On 
the  top  of  the  head  there  was  an  elevated  ulcerating  epithelioma 
almost  circular  in  outline  and  1|  inches  in  diameter.  The  diag- 
nosis of  carcinoma  was  confirmed  microscopically.  Between 
July  28  and  August  11,  1902,  each  area  was  given  twelve  expo- 
sures at  5  cm.  and  of  five  minutes'  duration.  A  trace  of  erythema 
developed  upon  both  lesions  on  August  11,  and  exposures  were 
discontinued  until  August  27.  Between  August  27  and  Septem- 


ere 

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W 
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t 


447 


CR 

— 
O 


29 


449 


REPORT  OF    CASES.  451 

her  29,  twelve  exposures  were  given  at  a  distance  of  5  cm.  and 
of  five  minutes '  duration.  Under  these  exposures  both  lesions 
cleaned  up  rapidly.  On  the  face  the  nodules  shrunk  and  dis- 
appeared. On  the  scalp  the  ulcers  sank  to  the  level  of  the 
normal  skin,  dried  up,  and  rapidly  became  smaller.  On  October 
1  the  ulcer  on  the  top  of  the  head  had  entirely  healed.  It  was 
replaced  by  smooth,  perfectly  healthy  looking  scar  tissue  with 
no  suspicious  nodules  at  any  point.  A  similar  transformation 
had  taken  place  in  the  lesion  on  the  face.  All  the  nodules  are 
gone  and  the  scar  remaining  is  slight. 

Case  68. — Man,  aged  sixty-two,  referred  to  me  by  Prof.  J.  B. 
Murphy,  of  Northwestern  University.  Ten  months  ago  a  little 
nodule  appeared  on  the  outer  half  of  the  lower  right  eyelid. 
Other  nodules  developed  until  the  outer  half  of  the  lid  was  in- 
volved. The  disease  had  been  treated  by  electrolysis,  and  ex- 
cision had  been  advised.  The  condition  at  the  time  of  his  com- 
ing to  me  is  shown  in  figure  141.  There  was  a  group  of  hard, 
waxy  nodules  involving  nearly  the  entire  outer  half  of  the  palpe- 
bral  border  of  the  lower  lid.  The  conjunctiva  was  not  involved. 
The  mass  was  a  little  over  1  cm.  long  and  half  as  thick.  At  one 
point  there  was  an  ulcer  the  size  of  a  split  pea.  The  diagnosis  of 
epithelioma  had  been  made  by  Dr.  Murphy  and  others  and  was 
above  question.  This  patient  received  forty-two  exposures 
between  August  15  and  October  4,  with  the  development  at 
times  of  slight  dermatitis  and  gradual  shrinking  of  the  lesions, 
until  by  September  15  no  nodules  remained.  The  treatment  at 
the  last  was  carried  to  the  point  of  producing  a  slight  superficial 
x-ray  burn,  which  rapidly  healed  and  left  a  smooth,  soft,  healthy 
looking  scar,  as  shown  in  figure  142.  The  lid  is  normal  in  appear- 
ance, and  without  distortion. 

Case  69. — Mr. ,  aged  ninety-eight,  referred  to  me  by 

Dr.  E.  J.  Dohring,  of  Chicago,  with  a  superficial,  freely  movable 
epithelioma,  the  size  of  a  little  finger-nail,  on  the  tip  of  the  nose. 
This  lesion  was  given  fifteen  moderate  exposures  between 
August  18  and  September  3,  1902,  with  the  production  of  a 
slight  dermatitis,  after  which  the  exposures  were  stopped.  Its 
disappearance  in  two  weeks  was  accompanied  by  the  formation 
of  a  healthy  scar  at  the  site  of  the  epithelioma.  This  patient 


452  CUTANEOUS    CARCINOMA. 

had  several  patches  of  senile  keratosis  on  the  face;  two  of  these, 
the  size  of  a  finger-nail,  were  inflamed  and  showed  beginning 
carcinomatous  degeneration.  Each  of  these  was  given  six 
exposures  of  five  minutes  at  5  cm.  distance  between  September 
8  and  September  15,  and  one  exposure  on  September  15  at 
5  cm.  of  fifteen  minutes'  duration.  These  exposures  were  fol- 
lowed in  either  patch  by  slight  dermatitis,  which  resulted  in  ex- 
foliation of  the  horny  masses  and  in  leaving  the  areas  smooth 
and  soft,  with  the  appearance  of  healthy  skin. 

Case  70. — Man,  aged  fifty-eight,  referred  to  me  by  Dr.  R.  J. 
Mitchell,  of  Girard,  111.  His  condition  at  the  time  of  coming  to 
me  is  poorly  shown  in  the  accompanying  photograph  (Fig.  143). 
There  was  a  tumor  an  inch  in  diameter  and  over  half  an  inch  high 
on  the  left  lower  lid.  There  was  a  profuse  purulent  discharge 
which  had  caused  a  severe  conjunctivitis.  The  pain  was  severe 
and  required  the  use  of  anodynes.  The  case  had  been  treated 
previously — once  by  excision,  and  from  March  to  June,  1902, 
vigorously  by  caustics — and  since  June  had  grown  very  rapidly. 
Between  August  21  and  September  22,  1902,  he  received 
twenty-six  x-ray  exposures,  at  an  average  distance  of  6  cm.  and 
of  an  average  duration  of  ten  minutes,  with  the  production  in 
the  end  of  a  slight  dry  dermatitis.  The  effect  of  the  x-ray  ex- 
posures was  very  prompt.  After  ten  exposures  he  had  no  more 
pain  and  the  tumor  began  to  shrink  rapidly.  Without  further 
exposures  the  lesion  gradually  disappeared,  and  by  October  15 
was  replaced  by  a  healthy  scar.  There  is  no  ectropion  and  the 
eye  is  not  damaged  (Fig.  144). 

In  treating  this  case  I  was  hampered  by  the  existence  of  a 
very  acute  conjunctivitis,  with  chemosis,  caused  by  the  constant 
bathing  of  the  eye  with  pus  from  the  ulcerating  tumor,  and  there 
was  imminent  danger  of  ulceration  of  the  cornea.  The  eye, 
therefore,  was  protected  very  carefully  against  the  x-rays.  This 
conjunctivitis  was  treated  with  boric  acid  and  protargol  in  the 
usual  manner,  and  by  the  time  the  tumor  had  disappeared  the 
conjunctivitis  had  also  disappeared. 

This  patient  also  had  a  beginning  superficial  epithelioma  of 
the  lower  lip,  involving  almost  its  entire  extent,  which  unfor- 
tunately does  not  show  well  in  the  photograph.  For  this  he  was 


Fig.  141. — Carcinoma  of  the  lower  eyelid. 


Fig.  142. 


453 


4.", 


REPORT   OF    CASES.  457 

given  fourteen  exposures  at  an  average  distance  of  6  cm.  and  of 
an  average  length  of  eight  minutes.  A  quite  acute  dermatitis 
was  produced,  which  was  followed  by  the  exfoliation  of  the  thick 
horny  masses  covering  the  lesion  and  the  subsequent  smooth 
healing  of  the  lip.  The  lip  since  October  1  has  been  smooth  and 
soft  and  free  from  suspicious  points,  and  without  perceptible 
scar.  The  present  condition  of  the  patient  is  shown  in  figure  144. 

The  next  three  cases  are  placed  out  of  their  chronological  order 
because  they  can  be  considered  more  conveniently  last. 

Case  71. — Woman,  aged  sixty,  referred  to  me  by  Dr.  A.  E. 
Baldwin,  of  Chicago,  with  an  enormous  epithelioma  which  had 
destroyed  the  left  eye  and  eyebrow,  involved  the  entire  orbit, 
spread  down  over  the  cheek  to  the  level  of  the  nostrils,  involved 
the  entire  left  side  of  the  nose,  and  extended  over  the  right  side 
of  the  nose  almost  to  the  inner  canthus  of  the  right  eye.  The 
disease  developed  many  years  ago  and  had  been  operated  upon 
several  times  and  treated  numerous  times  with  plasters.  The 
present  ulcer  had  been  growing  for  seven  years.  The  eye  had 
recently  been  destroyed  by  the  process,  and  at  the  time  of  be- 
ginning treatment  she  was  suffering  great  pain.  The  condition 
at  the  time  of  beginning  treatment,  January,  1902,  is  shown  in 
figure  145.  From  January  20,  1902,  to  December  1,  1902,  this 
patient  has  had  more  or  less  constant  treatment.  She  has  had 
treatment  every  other  day  for  periods  of  three  or  four  weeks, 
and  then  remissions  for  a  while,  followed  by  further  periods  of 
treatment.  Promptly  with  the  beginning  of  treatment  the  pain 
disappeared  and  the  ulcer  began  to  contract.  The  condition  at 
the  present  time  and  for  several  months  past  is  shown  in  figure 
146.  There  is  no  induration  of  the  borders  of  the  ulcer,  and  indeed 
no  nodules  can  be  found  at  any  point.  The  course  of  the  disease 
has  been  practically  checked  from  the  beginning  of  treatment. 
Whether  it  will  ever  be  possible  to  fill  up  this  large  deep  cavity 
is  altogether  doubtful,  but  the  result  illustrates  what  may  be 
done  in  checking  so  desperate  a  case.  The  patient  has  suffered 
almost  no  pain  since  ten  days  after  the  beginning  of  treatment. 
The  disease  not  only  has  not  spread,  but  its  borders  have  been 
very  much  reduced.  The  right  eye,  which  bid  fair  to  become 
involved  very  quickly,  has  been  saved.  Altogether,  from  an 


458  CUTANEOUS   CARCINOMA. 

aggressive  rapidly  spreading  destructive  process  the  condition 
has  been  changed  into  an  inactive  ulcer  which  has  lost  almost 
all  of  the  qualities  of  malignancy. 

I  have  treated  one,  and  only  one,  case  of  epithelioma,  which 
must  be  set  down  as  a  failure,  after  a  fair  trial : 

Case  72. — Man,  aged  sixty-five,  from  the  Illinois  Eye  and  Ear 
Infirmary.  This  patient  had  a  very  deep-seated  epithelioma, 
extending  across  the  root  of  the  nose  and  involving  the  inner 
canthus  of  the  right  eye.  The  lesion  was  nearly  an  inch  long, 
less  than  half  an  inch  wide,  and  quite  deep  (Fig.  147).  This 
patient  has  been  persistently  treated  from  February  24,  1902, 
and  the  reaction  has  been  carried  several  times  to  the  pro- 
duction of  an  acute  burn  with  superficial  necrotic  membrane. 
Apparently  there  has  been  no  effect,  except  to  prevent  spreading. 
The  lesion  has  not  increased  in  size,  but  it  has  not  decreased; 
and,  more  significant  still,  I  have  been  unable  to  get  rid  of  all  the 
nodules.  Why  this  has  been  so  in  this  case  it  is  hard  to  ex- 
plain. It  is  perhaps  a  question  altogether  of  idiosyncrasy. 
There  is  nothing  in  the  character  of  the  tumor  to  indicate 
that  it  differs  in  any  respect  histologically  from  numerous 
carcinomata  which  have  promptly  yielded.  The  case  illus- 
trates the  fact  that  carcinomata  differ,  as  do  patients,  very 
markedly  in  their  susceptibility  to  x-rays.  The  only  effect, 
thus  far,  in  this  case  has  been  the  checking  of  the  growth  and 
the  relief  of  pain.  The  patient  formerly  suffered  extreme  pain, 
which  ceased  after  the  first  x-ray  reaction.  The  case  is  still 
under  treatment.  [Within  the  last  month,  since  the  above  was 
written,  there  has  been  very  great  improvement  in  this  case,  so 
that  there  is  apparently  a  good  chance  of  cure.  The  improve- 
ment is  manifest  on  comparing  his  condition  December  18, 
1902  (Fig.  148),  with  figure  147.] 

Case  73. — Figures  149,  150,  and  151  are  inserted  to  illustrate 
the  changes  seen  in  a  rapidly  growing  deep-seated  carcinoma  of 
the  skin  under  treatment.  In  figure  149  are  seen  the  nodular 
masses  on  the  cheek  which  indicate  a  severe  type  of  cutaneous 
carcinoma.  In  figures  150  and  151  is  seen  the  ulcer,  healing 
under  treatment ;  the  nodular  masses  have  entirely  disappeared, 


459 


461 


463 


SUMMARY   OF    RESULTS.  465 

and  in  their  places  we  have  an  apparently  benign  clean  ulcer, 
whose  borders  are  rapidly  contracting. 

Of  the  above  twenty-seven  cases,  twenty-one,  or  77.7  %,  are, 
as  far  as  can  be  told  by  their  present  condition,  cured — numbers 
48,  49,  51,  52,  54,  55,  56,  57,  58,  59,  60,  61,  62,  63,  64,  65,  66,  67, 
68,  69,  70.  Of  these  twenty-one  cases,  seven  have  been  well 
eight  months  or  more,  as  follows : 

Case  No.  48  has  been  well  15  months. 

"      "     49    "       "        "     10        " 

"      "     51    "       "        "     11        " 
Cases  Nos.  52  and  54  have  been  well  9  months. 

"        "      55  and  56     "       "        "     8       " 

The  length  of  time  that  the  remaining  fourteen  have  been  well 
varies  from  six  months  to  a  few  weeks.  Of  course,  sufficient 
time  has  not  elapsed  to  judge  as  to  the  permanency  of  the  re- 
sults, but  from  the  results  in  the  cases  which  have  gone  longest, 
and  from  the  character  of  the  scars,  I  think  there  is  no  doubt 
that  these  scars  will  not  show  any  larger  proportion  of  recur- 
rences than  is  seen  in  favorable  cases  of  epithelioma  treated  by 
other  methods.  And  of  these  cases  by  no  means  all  were  favor- 
able cases  for  surgical  operation.  Cases  49,  54,  56,  62,  and  65 
were  insignificant  epitheliomata  that  might  easily  have  been 
handled  by  any  method  of  treatment.  Perhaps  the  advocates 
of  the  use  of  pastes  in  the  treatment  of  epithelioma  would  say 
that  also  Cases  48,  51,  55,  64,  66,  and  69  could  have  been  handled 
as  well  by  the  use  of  caustic  pastes,  but  they  could  not  have  been 
handled  more  successfully,  I  am  sure,  and  there  would  have 
been  more  scarring,  to  say  nothing  of  the  pain  of  the  treatment. 
Cases  60,  61,  66,  and  67  would  have  required  rather  extensive 
plastic  operation  to  get  rid  of  them  surgically.  Cases  52,  58,  59, 
68,  and  70  were  all  epitheliomata  involving  the  eyelids,  and  their 
surgical  treatment  would  have  required  the  plastic  restoration 
of  the  lids,  and  the  sacrifice  of  the  eye  in  some  of  the  cases. 
Case  63  was  a  carcinoma  of  the  penis  which  had  failed  of  treat- 
ment both  by  caustics  and  by  surgical  operation.  Indeed,  while 
many  of  these  cases  would  be  considered  amenable  to  ordinary 
treatment,  the  fact  remains  that  a  good  proportion  of  them  had 

30 


466  CUTANEOUS   CARCINOMA. 

had  other  forms  of  treatment  at  competent  hands  without 
success. 

Of  the  four  cases  which  show  recurrence,  only  one  has  shown  a 
recurrence  comparable  in  severity  with  the  original  disease. 
This  was  Case  53,  and  it  was  entirely  inadequately  treated, 
through  the  negligence  of  the  patient.  The  other  three  cases 
were  cases  which  presented  grave  obstacles  to  surgical  treat- 
ment. Cases  46  and  47  had  failed  of  cure  in  the  hands  of 
most  competent  surgeons.  It  had  not  been  regarded  as  feasible 
in  Case  46  to  make  any  further  attempts  at  treatment,  and  in 
Case  47,  wrhich  had  had  vigorous  surgical  treatment  in  competent 
hands  extending  over  many  years,  the  only  surgical  measure  left 
was  the  total  removal  of  the  nose,  which  the  patient  refused. 
The  recurrence  in  Case  46  was  only  an  epithelioma  the  size  of  a 
small  pea,  which  would  have  offered  no  difficulty  of  treatment 
by  x-rays  or  curetting  or  caustics,  or  any  other  method.  In 
Case  47  the  nose  has  been  saved.  For  several  years  previous  to  be- 
ginning treatment  the  entire  nose  had  been  ulcerating,  and  this  had 
necessitated  the  wearing  of  an  unsightly  bandage  all  the  time. 
All  that  trouble  has  been  escaped,  and  the  only  recurrence  has 
been  a  small  subcutaneous  nodule  below  the  eye,  which  required 
only  a  simple  operation  for  its  removal.  Case  50,  which  in- 
volved the  auditory  canal  for  its  external  half  inch,  and  a  large 
part  of  the  external  ear,  would  have  required  for  its  relief  the 
destruction  of  the  external  ear  and  an  extensive  destruction  of 
tissue  in  order  to  get  rid  of  the  epithelioma  in  the  auditory  canal. 
It  was  practically  inoperable.  The  only  recurrence  in  this  case 
was  a  small  lesion  the  size  of  a  French  pea  in  the  concha,  which, 
for  convenience,  I  destroyed  with  Bougard's  paste,  and  which 
gave  no  trouble.  Case  59  was  totally  beyond  relief  by  any  other 
method,  and  the  result  is  a  striking  illustration  of  the  possi- 
bilities of  this  method.  Without  x-rays  nothing  was  left  for  this 
patient  except  the  prospect  of  destruction  of  the  face  and  a 
miserable  end. 

Two  of  the  cases  still  show  some  lesion — Cases  71  and  72. 
Case  71  was  beyond  the  point  of  successful  treatment  otherwise. 
Its  course  has  been  checked  and  the  patient 's  suffering  stopped, 
a  result  that  may  be  regarded,  I  believe,  as  satisfactory.  Case 


SUMMARY    OF    RESULTS.  467 

71  is  a  failure  that  must  be  charged  against  the  method.  [Subse- 
quent developments  in  this  case  indicate  that  my  estimate  of  it 
was  too  conservative,  as  it  is  now  almost  well  (see  Fig.  148).] 

In  26  of  the  27  cases,  or  96.35  %,  this  method  of  treatment 
has  done,  I  believe,  all  that  could  be  fairly  expected  of  it  or  of 
any  other  method.  When  there  is  some  fact  to  detract  from 
the  completeness  of  the  results,  it  is  due  rather  to  some  in- 
superable difficulty  in  the  case  than  to  any  inadequacy  of  the 
method.  Only  one  case  can  be  charged  up  against  the  method 
as  an  unmitigated  failure;  and  a  record  of  only  3.75  failures  in 
cases  which  presented  such  difficulties  as  these  did  is,  it  would 
seem,  a  satisfactory  showing. 

The  cosmetic  excellence  of  the  scars  after  treatment  with  rr-rays 
has  been  noted  by  many  observers.  There  is  less  scarring  than 
follows  any  other  method  of  treatment,  and  the  scars  that  do 
occur  are  soft,  smooth,  of  the  color  of  the  normal  skin  or  white, 
and  entirely  healthy  looking.  The  fact  that  practically  no 
destruction  of  healthy  tissue  takes  place  is  a  marked  advantage 
of  the  method  in  treating  lesions  at  points  where  there  is  little 
tissue  to  be  spared,  as  about  the  eyelids. 


CHAPTER  XII. 

CARCINOMA  OF  THE  BREAST  AND  IN  THE 
THORAX. 

Carcinoma  of  Breast. — There  are  now  a  considerable  number 
of  reports  in  the  literature  upon  the  use  of  x-rays  in  the  treat- 
ment of  carcinoma  of  the  breast,  and  at  the  present  time  there  is 
every  evidence  that  the  method  is  being  given  a  very  wide  trial, 
much  wider  than  the  extent  of  the  literature  upon  the  subject 
would  indicate.  Among  those  who  have  treated  carcinoma  of 
the  breast  by  this  method  are  Gocht,*  Hopkins, f  C.  W.  Allen,! 
Eijkman,§  Johnson  and  Merrill,  ||  Morton,**  Ayers,ft  Clark,  H 
Soiland,§§  Williams.  ||  || 

So  long  ago  as  1897  Gocht  reported  two  cases  of  inoperable 
mammary  carcinoma  which  he  had  exposed  to  x-rays.  The  first 
case  received  six  daily  exposures,  with  almost  entire  relief  of 
pain.  In  the  second  case  death  took  place  before  improvement 
could  be  expected. 

Hopkins  has  reported  two  cases  of  carcinoma  of  the  breast 
treated  by  this  method.  The  first  case  was  a  primary  carcinoma 
of  the  breast  in  which  the  involved  breast  was  twice  as  large  as 
the  other  and  after  thirty-two  treatments  decreased  to  practi- 
cally its  normal  size;  in  the  mean  time  all  subjective  symptoms 
ceased.  In  the  second  case,  an  ulcerating  carcinoma  of  the 
breast,  there  has  been  disappearance  of  pain  and  odor  and  de- 
crease in  size. 

*  Fortschr.  a.  d.  Geb.  d.  Rontgenstrahlen,  1897,  i,  p.  14. 
tPMla.  Med.  Jour.,  1901,  viii.  p.  404. 
J  N.  Y.  State  Jour,  of  Med.,  1902,  ii,  p.  176. 
\  "Krebs  und  Rontgenstrahlen.''  Haarlem,  1902. 
||  American  Medicine.  1902,  iv.  p.  217. 
**  Med.  Record,  1902,  Ixi,  pp.  361,  801. 
tfKan.  City  Med.  Index-Lancet,  1902,  xxiii,  p.  18. 
Jt  Brit.  Med.  Jour.,  1901,  i,  p.  1398. 
?g  Southern  Califor.  Practitioner,  1902,  xvii,  p.  140. 
IHI  "The  Riintgen  Rays  in  Medicine  and  Surgery,"  p.  670. 
468 


CARCINOMA    OF    BREAST.  469 

Ferguson  *  reports  an  inoperable  recurrent  scirrhous  growth 
the  size  of  a  hen's  egg  on  the  manubrium  of  the  sternum,  for 
which  he  advised  the  use  of  the  Rontgen  rays.  They  were 
applied  for  twenty  minutes  on  as  many  days.  After  a  month's 
absence  the  patient  returned  in  excellent  health  and  spirits.  The 
sternal  growth  had  completely  disappeared,  the  ulcerated  sur- 
face below  the  growth  had  healed,  and  the  pain — considerable 
before — had  greatly  lessened,  being  confined  to  the  arm  alone, 
the  swelling  of  which  had  diminished.  There  was  still  some 
deposit  around  the  axillary  vein. 

Soiland  has  reported  the  case  of  a  woman  with  a  carcinomatous 
ulcer  the  size  of  a  dollar  on  the  left  breast  with  indurated  nodules 
around  it.  After  six  weeks  of  exposures  every  other  day  all 
external  manifestations  disappeared;  the  ulcer  healed,  the  skin 
over  the  gland  became  movable,  there  was  no  pain,  and  the 
general  health  of  the  patient  was  improved.  There  were  still 
a  few  hard  nodules  in  the  gland. 

Ayers  has  reported  two  cases  of  mammary  carcinoma  treated 
by  this  method.  In  the  first  case  evidence  of  recurrence  was 
seen  before  healing  of  the  wound  after  operation.  At  the  be- 
ginning of  treatment  there  was  an  indurated  mass  two  inches 
below  the  scar.  This  case  was  given  exposures  of  four  minutes 
daily  for  three  and  a  half  months,  at  the  end  of  which  time  all 
induration  had  disappeared.  The  cicatrix  was  normal,  the  skin 
soft  and  flexible,  and  there  was  no  pain.  In  the  second  case  the 
tissues  of  the  upper  half  of  the  left  side  of  the  chest  were  in- 
durated and  immovable,  with  three  ulcers,  each  the  size  of  a 
lemon,  and  there  was  a  large  indurated  mass  in  the  axilla. 
There  had  been  several  hemorrhages  from  the  surface.  As 
result  of  treatment  there  has  been  marked  improvement.  The 
tissues  are  much  softer  and  more  movable,  the  nodules  are 
shrunken,  and  the  mass  is  reduced  to  one-third  its  previous  size. 

Andrew  Clark  has  made  a  preliminary  report  upon  an  inter- 
esting case  treated  by  this  method.  The  patient,  a  woman  aged 
sixty,  had  been  in  Middlesex  Hospital  in  1894  for  a  tumor  of  the 
breast  which  had  been  recognized  as  carcinoma  and  for  which 
operation  had  been  advised  and  declined.  She  was  again  in  the 

*Brit.  Med.  Jour.,  1902,  i,  p.  265. 


470        CARCINOMA   OF   THE    BREAST   AND   IN   THE    THORAX. 

hospital  in  1898.  In  1901  the  tumor  had  enlarged  and  ulcerated 
and  become  very  painful,  so  that  she  sought  readmission  to  the 
hospital.  The  induration  and  ulceration  had  extended  gradu- 
ally. On  March  6,  1901,  at  the  suggestion  of  Mr.  Clifford,  the 
house  surgeon,  x-ray  exposures  were  begun,  and  the  exposures 
had  been  continued  five  days  a  week  for  nine  weeks  at  the  time 
of  the  report.  On  March  9  there  was  a  note:  "Breast  a  little 
cleaner,  numerous  islands  of  epithelium  present."  April  14: 
"  Appearance  of  breast  still  improving;  much  less  pain."  April 
23:  "Still  free  improvement  in  the  ulceration  and  diminution 
in  the  size  of  the  indurated  lump."  On  May  14  the  induration 
had  become  much  less  and  the  patient  had  little  pain.  The 
glands  in  the  axilla  were  smaller  and  her  general  condition 
improved. 

C.  W.  Allen  has  reported  one  case  of  recurrent  carcinoma 
of  the  breast  with  nodules  in  the  other  breast  which  is  "prac- 
tically well."  He  also  reports  improvement  in  five  other  cases 
of  recurrent  carcinoma  of  the  breast.  Eijkman  has  reported 
one  case  of  carcinoma  of  the  breast,  with  involvement  of  the 
axilla,  in  which  almost  all  evidence  of  disease  has  disappeared. 
Morton  has  reported  one  case  of  carcinoma  of  the  breast  symp- 
tomatically  cured,  and  three  others  improved. 

On  the  other  hand,  Johnson  and  Merrill  have  reported  four 
cases  of  mammary  carcinoma  treated  by  this  method,  none  of 
which  were  improved. 

I  have  treated  25  successive  cases  of  carcinoma  of  the  breast 
in  which  the  results  allow  some  opinion  to  be  formed  as  to  the 
efficiency  of  the  treatment.  Of  these,  18  cases  were  recurrent 
carcinoma  of  the  breast,  and  7  cases  were  primary  carcinoma 
of  the  breast.  I  have  also  given  x-ray  exposures  to  14  cases  as 
a  prophylactic  measure  after  operations  for  carcinoma  of  the 
breast  and  before  any  evidence  of  recurrence  had  appeared. 

Recurrent  Carcinoma  of  Breast. — Case  74. — Mrs. .  aged 

thirty-eight.  A  very  extensive  recurrent  carcinoma  of  the 
breast  with  involvement  of  axilla  which  had  been  passed  upon 
as  inoperable  by  Dr.  Charles  McBurney,  of  Xew  York.  This 
was  the  first  case  of  the  sort  that  I  attempted  to  treat  and  was 
early  in  the  history  of  the  method,  and  the  chances  of  benefit 


RECURRENT   CARCINOMA   OF   BREAST.  4?1 

seemed  so  infinitesimal  that  with  my  concurrence  the  treatment 
was  discontinued  after  five  weeks.  There  was  no  positive 
benefit. 

Case  75. — Mrs.  ,  aged  forty-eight,  referred  to  me  on 

July  18,  1901,  with  the  following  history:  Six  years  ago  she 
had  an  operation  by  Prof.  E.  C.  Dudley,  of  Northwestern 
University,  for  laceration  of  the  cervix,  and  her  general  health 
had  been  bad  for  several  years  with  complete  nervous,  break- 
down but  without  demonstrable  lesion.  The  family  and  per- 
sonal history  contains  no  salient  facts.  In  1899  a  tumor 
developed  in  her  right  breast,  which  was  recognized  as  a  carci- 
noma, and  in  April,  1900,  was  removed.  Recurrence  became 
evident  in  the  scar  six  months  after  removal,  in  the  fall  of- 
1900.  In  the  spring  of  1901  she  was  seen  by  Prof.  Christian 
Fenger,  of  Rush  Medical  College,  and  the  case  pronounced 
inoperable.  The  condition  when  she  came  to  me  eight  months 
after  recurrence  is  shown  in  the  accompanying  photograph 
(Fig.  152).  On  the  right  side  of  the  chest  between  the  site  of 
the  nipple  and  the  axilla  was  a  dense,  hard,  nodular  mass  six 
inches  in  diameter  attached  to  the  ribs.  The  cicatrix  was 
star-shaped  and  the  center  of  it  was  a  mass  of  closely  grouped 
waxy  nodules  which  were  ulcerating.  In  the  axilla  was  a  mass 
of  indurated  scar  tissue,  but  no  glands  were  palpable  there. 
The  arm,  however,  was  enormously  swollen  and  tense  down  to 
the  very  fingers.  There  were  no  glands  palpable  in  the  supra- 
clavicular  region.  She  was  suffering  very  severe  pain,  for  which 
morphin  was  necessary. 

The  case  was  put  under  daily  exposures  at  5  cm.  distance 
and  of  fifteen  minutes'  duration,  July  18,  1901,  and  by  August 
13,  after  twenty  exposures,  a  marked  dermatitis  had  been 
caused  over  the  entire  area,  and  a  bulla  had  formed  over  the 
center  of  the  mass.  The  treatment  had  been  as  vigorous  as 
I  dared,  because  it  seemed  evident  that  if  anything  was  to  be 
done  it  had  to  be  done  quickly.  This  effect  disappeared  by 
September  2,  when  the  entire  surface  was  healed  over  and  the 
discharge  ceased.  At  the  same  time  there  was  a  very  marked 
shrinkage  of  the  nodules  and  disappearance  of  the  osdema  of 
the  arm.  With  the  exception  of  an  interval  of  six  weeks,  when 


472        CARCINOMA    OF   THE    BREAST    AND    IN    THE    THORAX. 

the  patient  had  an  acute  illness  not  connected  with  her  car- 
cinoma, she  had  vigorous  exposures  almost  daily  from  September 
2  to  December  4 — thirty-one  in  all.  An  acute  dermatitis  was 
again  set  up  in  the  latter  part  of  October,  but  after  that  date 
the  exposures  were  never  carried  to  the  point  of  producing  an 
acute  reaction.  On  November  8  I  made  the  following  note: 
"The  dermatitis  has  entirely  disappeared,  the  skin  is  of  normal 
color  except  for  pigmentation  around  the  periphery  of  the 
exposed  area.  The  skin  where  the  tumor  existed  is  smooth, 
and  it  is  impossible  at  present  to  find  any  evidence  of  carcinoma 
in  the  area.  All  of  the  nodules  have  entirely  disappeared." 
The  condition  at  that  time  is  shown  in  figure  153,  for  which 
I  am  indebted  to  an  amateur  photographer. 

From  December  1,  1901,  to  May  1,  1902,  this  patient  received 
several  series  of  irregular  exposures  without  at  any  time  showing 
marked  reaction.  From  May  1  to  November  1,  1902,  there 
were  practically  no  exposures.  The  condition  of  the  arm  and 
the  condition  of  the  chest-wall  still  remains  to  date  [December 
1,  1902]  as  satisfactory  as  it  was  in  November,  1901,  with  the 
exception  that  in  November,  1902,  two  small  nodules  the  size 
of  a  split  pea  developed  at  the  center  of  the  cicatrix. 

This  patient's  general  condition  was  bad  at  the  beginning  of 
treatment  and  it  remains  bad  at  the  present  time.  In  the 
spring  of  1901  we  were  very  much  afraid  of  pelvic  carcinoma. 
Our  fears  in  that  direction  proved  groundless,  but  at  present 
there  are  pressure  symptoms  referable  to  the  lower  part  of  the 
cord,  due  probably  to  beginning  metastasis  in  the  lumbar 
vertebra. 

The  disappearance  of  the  oedema  of  the  arm  in  this  case  is, 
of  course,  a  most  instructive  fact.  When  it  occurred  it  gave 
evidence,  much  needed  at  that  time,  of  the  deep  effect  of  x-rays. 

Case  76. — The  following  report  of  this  case  was  made  Feb- 
ruary, 1902:  Mrs.  ,  aged  fifty-eight,  referred  to  me  by 

Dr.  C.  C.  Gratiot,  of  Shullsburg,  Wis.  The  patient  was  in 
Dr.  Christian  Fenger's  care  in  Passavant  Hospital  in  July  and 
August,  1900,  and  the  following  facts  are  taken  from  the  hospital 
record,  which  Dr.  Fenger  kindly  placed  at  my  disposal:  "Her 
present  [July,  1900]  trouble  began  about  six  years  ago,  when 


473 


REPORT  OF   CASES.  475 

patient  noticed  a  little  hard  lump  on  the  inferior  aspect  of  the 
left  breast  on  the  axillary  side.  There  was  a  scarcely  perceptible 
enlargement  of  the  hard  area  until  about  two  years  ago,  when 
the  patient  noticed  a  more  rapid  enlargement.  She  then  con- 
sulted Dr.  Sheldon,  of  Madison,  Wis.  At  that  time  this  growth 
developed  very  fast  and  broke  through  the  skin  and  formed 
an  open  sore,  which  grew  in  dimensions  until  it  is  now  the  size 
of  a  silver  dollar.  Dr.  Sheldon  advised  an  operation,  where- 
upon she  consulted  Dr.  Fenger."  Dr.  Fenger  removed  the 
breast  with  the  axillary  and  supraclavicular  glands  in  July, 
1900.  A  few  months  after  removal  the  disease  reappeared  in 
the  scar.  She  returned  to  Dr.  Fenger  last  summer,  but  he 
found  the  case  beyond  operation.  Her  condition  when  she  came 
to  me,  November  1,  1901,  is  shown  in  the  accompanying  photo- 
graph (Fig.  154).  As  seen  in  the  illustration,  there  was  a  mass 
of  carcinomatous  tissue  on  the  left  side  involving  an  area  of 
about  a  square  foot.  The  nodules  varied  from  the  size  of  a 
hazelnut  to  that  of  a  small  apple.  At  the  upper  inner  angle 
there  were  a  couple  of  ulcers  2^  to  3  inches  in  diameter.  Around 
the  main  mass,  and  separated  from  it  by  distances  of  from  two 
to  three  inches  or  more,  were  numerous  hazelnut-sized  nodules. 
She  had  on  two  occasions  suffered  alarming  hemorrhage  from 
the  surface.  Dr.  Fenger  had  thoroughly  removed  the  glands 
in  the  axilla  and  above  the  clavicle,  and  no  enlarged  glands 
in  either  of  these  locations  were  found.  When  she  began 
treatment,  she  was  suffering  a  great  deal  of  pain.  She  was  so 
weak  that  a  nurse  had  to  bring  her  by  easy  stages  from  the 
nearest  hotel  for  her  treatments,  and  she  was  in  every  way 
thoroughly  haggard  and  worn. 

She  was  put  under  x-ray  exposures  on  November  1,  and 
the  sittings  were  given  daily  for  two  months,  and  every  other 
day  or  less  frequently  after  that.  Two  weeks  after  the  treat- 
ments were  begun  she  volunteered  the  statement  that  her  pain 
was  gone,  and  she  has  had  none  since.  On  January  17  I  made 
the  following  note:  "There  has  been  rapid  subsidence  of  the 
tumor  for  the  last  month.  The  improvement  can  be  seen  from 
week  to  week.  There  is  at  present  only  a  slight  superficial 
ulceration  about  the  size  of  a  dime  at  one  point  and  one  small 


476         CARCINOMA    OF   THE    BREAST   AND    IX    THE    THORAX. 

nodule  the  size  of  a  pea.  The  surface  is  free  from  infiltration 
and  thickening  and  the  redness  has  almost  disappeared.  The 
skin  is  considerably  pigmented."  (Fig.  155.)  Improvement  has 
continued  since  that  time.  The  condition  February  27,  1902, 
is  indicated  in  the  accompanying  photograph  (Fig.  156).  There 
is  no  evidence  of  carcinoma  left  on  the  chest-wall.  There  is  a 
thin,  soft,  brownish-white  scar,  which  is  almost  freely  movable. 
Around  the  borders  of  the  scar  there  are  numerous  dilated 
capillaries,  the  remnants  of  the  previous  abundant  vascular 
supply  of  the  tumor.  It  seems  hardly  credible  that  this  scar 
represents  the  site  of  the  previous  tumor  mass. 

Her  general  condition  has  progressed  equally  well.  As  I  said 
above,  she  has  been  free  from  pain  since  ten  days  after  treat- 
ment wras  begun.  Since  January  1,  1902,  she  has  been  strong 
enough  to  come  in  alone  three  times  a  week  for  her  treatments 
from  a  town  thirty-five  miles  from  Chicago.  She  has  regained 
her  appetite  and  has  increased  in  flesh  decidedly  (10  to  15 
pounds).  Now  she  presents  the  picture  of  a  healthy  old  lady. 

The  first  series  of  treatments  in  this  case  were  ended  in  the 
middle  of  February,  1902,  and  the  patient  was  sent  home  to 
return  in  three  months.  In  May,  1902,  she  returned,  and  at 
that  time  the  scar  on  the  anterior  chest-wall  remained  smooth 
and  clean,  but  in  the  posterior  axillary  line  three  inches  below 
the  axilla  there  were  five  or  six  pea-sized  nodules  and  in  the 
right  axillary  space  there  was  a  filbert-sized,  movable,  hard 
gland.  Her  general  condition  was  excellent.  She  had  pre- 
viously suffered  from  a  hacking  cough,  which  bothered  her  no 
longer.  During  May  and  June,  1902,  she  had  rather  vigorous 
exposures,  with  the  production  of  an  acute  dermatitis,  which 
disappeared  slowly,  and  with  it  all  of  the  nodules.  The  gland 
in  the  right  axilla  also  disappeared  under  exposures. 

This  was  the  first  time  that  this  patient  had  had  an  acute 
dermatitis.  The  previous  lesions  were  removed  without  pro- 
ducing more  than  a  very  slight  dermatitis,  but  with  marked 
pigmentation.  From  the  middle  of  June  until  the  middle  of 
September,  1902,  she  had  no  treatment.  When  she  returned 
in  the  middle  of  September,  there  was  a  patch  in  the  anterior 
axillary  line  on  the  left  side,  formed  by  the  coalescence  of 


479 


REPORT   OF    CASES.  481 

several  flat  nodules  from  the  size  of  a  dime  down.  All  these 
nodules  were  hard,  dark  red,  and  not  tender.  There  were  two 
very  small  glands  palpable  on  the  left  side  of  the  neck,  none 
on  the  right.  There  was  a  gland  in  the  anterior  part  of  the 
right  axilla  the  size  of  a  dime,  and  a  small  gland  about  an  inch 
and  a  half  below  it  in  line  with  the  nipple.  She  was  having 
slight  pain,  but  not  enough  to  particularly  interfere  with  her 
comfort,  and  her  general  condition  was  good.  From  September 
13  to  October  6,  1902,  she  had  vigorous  exposures,  with  the 
production  of  an  acute  dermatitis,  upon  the  occurrence  of 
which  the  lesions  disappeared  in  all  of  the  locations.  December 
15,  1902,  she  remains  in  good  condition,  without  evidence  of 
carcinoma. 

As  may  be  seen,  there  have  been  two  minor  recurrences  in 
this  case,  and  of  course  it  could  not  be  said  that  the  patient 
is  in  any  way  relieved  from  the  prospect  of  further  recurrences. 
But  the  course  of  the  case  under  x-rays  has  been  of  a  character 
that  has  been  totally  unknown  in  such  cases  previously.  This 
patient  in  November,  1901,  was  in  a  condition  where  death  was 
inevitable  in  the  course  of  a  very  short  time.  She  had  been 
suffering  harassing  pain  for  months,  had  had  two  alarming 
hemorrhages  from  the  mass,  and  from  pain  and  anxiety  and 
loss  of  blood  she  was  reduced  in  strength  to  a  marked  degree. 
Her  physical  vigor  has  been  restored,  she  has  been  kept  free 
from  pain,  and  she  has  been  relieved  from  practically  all  mani- 
festation of  carcinoma  for  a  year.  This  case  tends  to  disprove 
the  idea  which  has  been  suggested,  that  after  a  certain  amount 
of  exposure  carcinomatous  tissue  is  no  longer  susceptible  to 
the  influence  of  x-rays.  It  has  certainly  been  as  easy  to  get 
rid  of  the  second  and  third  recurrences  as  of  the  first. 

Case  77. — Miss  ,  aged  forty-nine,  referred  to  me  by 

Dr.  A.  J.  Ochsner.  In  February,  1899,  she  noticed  a  hard 
lump  in  the  left  breast,  which  was  followed  by  gradual  retrac- 
tion of  the  nipple.  In  February,  1900,  the  breast  was  removed 
by  a  well-known  surgeon,  but  the  disease  soon  recurred  in  the 
scar,  and  in  October,  1900,  a  second  operation  was  done.  A 
second  recurrence  soon  showed  itself,  whereupon  she  consulted 
Dr.  Ochsner,  and  on  November  25,  1901,  he  referred  her  to 

31 


482        CARCINOMA    OF   THE    BREAST   AND    IX    THE    THORAX. 

me.  When  she  began  treatment  with  x-rays  there  were  two 
ulcers  about  the  middle  of  the  scar,  each  the  size  of  a  twenty- 
five-cent-piece,  surrounded  by  purplish-red  indurated  tissue. 
The  case  was  given  moderate  x-ray  exposures  from  November 
25,  1901,  to  January  27,  1902,  when  considerable  erythema 
developed  and  the  exposures  were  stopped  for  two  weeks.  With 
the  disappearance  of  the  dermatitis  the  ulcers  rapidly  grew 
smaller,  and  by  January  20  had  been  replaced  by  soft,  healthy 
scar  tissue.  After  the  disappearance  of  all  evidence  of  disease 
the  exposures  were  still  given  during  February,  March,  April, 
May,  and  June,  part  of  the  time  over  the  chest,  part  of  the 
time  in  the  axilla,  and  part  of  the  time  over  the  supraclavicular 
region,  and  she  had  similar  exposures  again  during  October 
and  November.  During  this  time  it  was  the  aim  to  keep  the 
reaction  below  the  point  of  producing  a  dermatitis,  but  very 
marked  pigmentation  was  produced.  There  has  never  been  any 
evidence  of  recurrence  of  the  disease  on  the  affected  side. 

In  May,  1902,  a  small,  hard,  disc-shaped  mass  was  discovered 
beneath  the  nipple  in  this  patient's  right  breast,  and  she  was 
immediately  put  under  x-ray  exposures  over  this  area  and  the 
corresponding  supraclavicular  and  axillary  areas.  The  expo- 
sures were  carried  to  the  point  of  producing  an  erythema  which 
became  a  bright  dry  dermatitis  and  then  subsided.  With  the 
subsidence  of  this  by  the  middle  of  July  the  mass  entirely  dis- 
appeared. This  patient  was  examined  by  Dr.  Ochsner  Novem- 
ber 1  last,  a  year  after  beginning  treatment,  and  he  wrote  me: 
"It  seems  to  me  that  Miss is  entirely  well." 

This  case  represents  the  type  of  recurrent  carcinoma  of  the 
breast  which  shows  the  best  results  from  the  use  of  x-rays. 
The  patient  had  had  a  primary  operation  and  one  operation 
for  recurrence,  and  a  vigorous  second  recurrence  had  begun. 
Every  one  knows  how  hopeless  it  is  to  attempt  further  surgical 
intervention  in  cases  of  this  character.  Further  operations 
offer  practically  no  hope  of  success,  even  when  there  is  enough 
tissue  left  on  the  chest-wall  to  make  an  operation  feasible.  In 
the  ordinary  course  of  events  nothing  except  the  early  death 
of  the  patient  was  to  be  expected.  In  this  case  the  patient  is 
w-ell  a  year  after  beginning  treatment,  she  is  in  vigorous  health, 


REPORT  OF   CASES.  483 

and  throughout  the  time  of  her  treatment  she  has  been  able  to 
pursue  an  exacting  occupation. 

Case  78. — Mrs.  ,  aged  forty-one,  referred  to  me  by 

Prof.  A.  J.  Ochsner,  of  the  University  of  Illinois.     In  November, 

1901,  Dr.   Ochsner   removed  a  carcinoma  of   the  breast  and 
enlarged  glands  in  the  axilla,  and  one  enlarged  gland  high  up 
under  the  subclavian  vein.     The  case  was  referred  to  me  for 
prophylactic  treatment  of  the  scar  on  the  left  side  and  for 
treatment  of  the  condition  of  the  right  nipple,  which  had  been 
diagnosticated  as  Paget's  disease.     The  disease  in  the  left  breast 
had  been  preceded  by  a  similar  affection  of  the  nipple.     At 
the  time  she  came  to  me  there  was  a  healthy  scar  on  the  left 
side.     The  right  breast  showed  no  induration  except  beneath 
the  nipple,  but  the  areola  and  nipple  were  involved  in  a  chronic 
dermatitis   of  several  years'  duration.    The  areola  was  red, 
covered  with  scales  and  crusts,   and  the  nipple  had  almost 
disappeared,  and  there  was  a  thick  disc  of  indurated  tissue 
beneath  the  areola. 

This   patient  had  between  November,   1901,   and  October, 

1902,  several  series  of  exposures  over  the  right  side  as  a  prophy- 
lactic.    She  was  given  twenty-two  exposures  over  the  diseased 
nipple  between  January  7  and  March  7,  1902,  with  the  produc- 
tion of  a  slight  erythema.     By  March  7  the  nipple  was  entirely 
well,  the  induration  was  gone,  and  it  has  remained  well  since 
that  time.    The  malignant  character  of  these  carcinomata  be- 
ginning in  the  areola  of  the  breast,  which  were  first  described 
by  Sir  James  Paget,  is  well  known,  as  is  their  intractability  to 
all  treatment  except  excision.     This,  I  believe,  is  the  first  case 
of  Paget's  disease  thus  treated  that  has  been  reported. 

Case  79. — Mrs.  ,  aged  seventy-eight,  referred  to  me 

by  Dr.  Christian  Fenger,  of  Chicago,  and  Dr.  Carl  E.  Black,  of 
Jacksonville,  111.  Eight  years  ago  a  tumor  developed  in  the 
left  breast,  which  was  removed  by  operation,  and  subsequently 
two  other  operations  were  done.  Dr.  Fenger  and  Dr.  Black 
advised  against  further  operation,  and  in  February,  1902, 
referred  her  to  me.  At  that  time  there  was  a  hard  mass  of 
glands  in  the  axilla  and  under  the  border  of  the  pectoral  muscle. 
The  supraclavicular  space  was  swollen  and  contained  a  hard 


484    CARCINOMA  OF  THE  BREAST  AND  IX  THE  THORAX. 

gland  almost  as  large  as  an  olive.  The  forearm  and  hand  were 
swollen  and  oedematous,  and  the  arm  was  considerably  larger 
than  the  other  arm,  but  was  only  slightly  oedematous,  the 
enlargement  being  due  to  connective-tissue  hyperplasia  from 
long-continued  lymphatic  obstruction  rather  than  to  cedema. 
She  was  run  down  physically  and  had  a  cough.  X-ray  expo- 
sures of  moderate  intensity  were  begun  over  the  pectoral  area 
and  the  axillary  and  supraclavicular  spaces,  and  were  con- 
tinued until  March  29, — twenty-five  exposures  in  all, — with  the 
production  of  a  moderate  dry  dermatitis  and  a  good  deal  of 
pigmentation.  At  that  time  the  swelling  in  the  forearm  and 
hand  had  almost  entirely  disappeared.  On  April  16  she  re- 
turned for  further  exposures,  the  dermatitis  having  subsided. 
There  wras  free  improvement  in  all  of  the  involved  areas. 

She  had  twelve  exposures  between  April  16  and  May  12  and 
no  further  exposures  until  August  1.  During  the  second  series 
of  exposures  there  was  a  very  marked  pigmentation  produced, 
but  no  dermatitis.  The  improvement  in  the  local  condition 
and  in  the  patient's  general  health  was  continuous.  By  May 
12  the  masses  in  the  border  of  the  pectoral  muscle  and  in  the 
axilla  were  very  much  smaller  and  softer  and  the  supraclavicular 
gland  was  soft,  though  still  palpable.  The  patient  w7as  feeling 
well  'and  vigorous,  had  no  pain,  and  altogether  there  was  a 
very  marked  improvement  in  her  condition;  this  in  spite  of  the 
fact  that  she  had  spent  the  months  of  March  and  April  in  the 
inclement  weather  of  Chicago,  which  was  unusual  for  her,  and 
had  exposed  herself  to  the  weather  very  much  more  than  was 
her  previous  custom. 

When  she  returned,  August  1,  for  further  treatment,  the 
improvement  had  continued.  There  w#s  no  evidence  of  re- 
currence of  the  growth  and  her  general  health  was  still  good. 
Between  August  1  and  September  12  she  received  30  exposures, 
without  the  production  of  any  reaction  except  a  marked  pig- 
mentation. Since  that  time  she  has  had  no  treatments.  At 
the  end  of  this  series  of  exposures  the  condition  remained 
good.  The  entire  affected  area  was  free  from  induration,  the 
axilla  soft,  and  the  gland  above  the  clavicle  as  soft  as  adipose 
tissue  and  almost  impalpable. 


REPORT   OF   CASES.  485 

Case  80. — Mrs. ,  aged  forty-six,  referred  to  me  by  Dr. 

G.  H.  Brannon,  of  Manhattan,  111.  For  many  years  she  had 
a  lump  in  the  left  breast,  which  last  year  began  to  increase 
in  size,  and  in  September,  1901,  was  removed.  There  was  some 
recurrence  in  the  scar,  and  this  was  removed  by  operation  a 
month  before  she  came  to  me.  At  the  time  that  she  was  re- 
ferred to  me,  April  28,  1902,  there  was  a  healthy  looking  scar 
attached  to  the  ribs,  but  in  the  axilla  was  a  large  mass  of  dense, 
hard,  indurated  glands,  and  above  the  clavicle  a  mass  of  hard 
glands  was  palpable.  The  arm  and  forearm  were  slightly 
oedematous.  The  patient's  general  health  was  very  markedly 
run  down.  The  condition  of  this  patient  at  the  time  of  coming 
under  treatment  was  as  closely  similar  as  possible  to  that  in 
the  preceding  case.  The  course  of  the  cases  under  x-rays  has 
also  been  identical.  This  patient  has  had  more  or  less  regular 
exposures  from  May  28,  1902,  to  date,  having  had  78  exposures 
of  fair  intensity  between  April  28  and  November  10.  In  this 
case  the  reaction  has  never  gone  beyond  the  production  of  a 
moderate  erythema.  A  condition  of  considerable  pigmentation 
has  been  maintained  almost  throughout.  The  improvement 
in  the  patient  has  been  continuous,  until  there  is  now  no  evidence 
of  carcinoma.  The  only  evidence  of  disease  above  the  clavicle 
is  a  soft  gland.  The  condition  of  the  patient's  general  health 
has  improved  correspondingly.  She  is  now  well  and  vigorous 
and  able  to  attend  to  her  ordinary  household  duties.  At  the 
beginning  she  was  just  able  to  drag  herself  about. 

Neither  this  case  nor  the  one  preceding  can,  of  course,  as 
yet  be  claimed  as  more  than  symptomatically  relieved,  and 
both  are  to  continue  treatment,  but  the  results  in  both  cases 
may  be  regarded,  I  believe,  as  highly  satisfactory.  These  were 
both  cases  of  the  type  of  slow-growing  carcinomata  that  gradu- 
ally wear  the  patient  out  and  that  are  totally  unamenable  to 
surgical  intervention.  Case  79  would  probably  have  lasted  for 
some  time;  Case  80  had  every  prospect  of  being  worn  out  in  a 
very  short  time. 

Case  81. — Mrs. ,  aged  forty-six,  referred  to  me  by  Dr. 

Kossuth  Tinker,  of  Athens,  Ohio.  In  May,  1901,  the  left 
breast  was  removed  for  carcinoma  of  a  few  months'  duration, 


486    CARCINOMA  OF  THE  BREAST  AND  IX  THE  THORAX. 

and  the  wound  remained  healthy  until  April,  1902.  At  that 
time  she  discovered  several  superficial  nodules  developing  in 
the  subcutaneous  tissue  of  the  chest-wall  along  the  line  of  the 
scar.  At  the  time  she  came  to  me  there  was  a  healthy  looking 
scar  except  for  a  half-dozen  nodules  the  size  of  a  large  marrow- 
fat pea  and  smaller.  These  were  indurated  and  purplish  in 
color,  and  unquestionably  carcinomatous.  The  axilla  and 
supraclavicular  areas  showed  no  induration,  but  the  arm  was 
swollen  and  there  was  a  good  deal  of  pain  in  the  shoulder. 
She  had  eighty-two  exposures  between  May  27  and  October  1, 
with  the  production  of  slight  erythema  on  several  occasions, 
and  toward  the  last  of  an  acute  dermatitis.  Under  the  treat- 
ment the  nodules  gradually  diminished  in  size  and  three  months 
after  beginning  treatment  had  entirely  disappeared. 

Case  82. — Mrs.  ,  aged  fifty-eight,  referred  to  me  by 

Dr.  TV.  B.  Young,  of  Bonair,  Tenn.  In  the  summer  of  1901  a 
small  lump  which  had  been  in  the  right  breast  for  many  years 
began  to  increase  in  size,  and  in  November,  when  it  had  attained 
the  size  of  a  fist,  was  removed  by  Dr.  Young.  Early  in  January, 
1902,  the  disease  recurred  in  the  scar,  and  after  that  time  spread 
rapidly  and  was  accompanied  by  severe  darting  pains.  At  the 
time  she  came  to  me,  May  1,  1902,  there  was  a  large  mass  about 
the  scar  on  the  right  side  of  the  chest,  the  induration  extending 
from  the  border  of  the  left  breast  to  the  posterior  axillary  line 
and  from  the  third  to  seventh  ribs  in  nipple  line.  The  mass 
was  of  a  brownish-red  color,  dotted  with  hard  reddish  nodules 
the  size  of  large  peas.  In  the  center  of  the  area  there  was  an 
ulcer  as  large  as  a  silver  quarter.  Xo  glands  were  palpable  in 
the  axilla,  but  the  tissues  were  indurated  and  brawny. 

She  was  put  under  rr-ray  exposures  and  received,  between 
May  1  and  September  11,  ninety-four  exposures,  with  the  pro- 
duction on  several  occasions  of  a  rather  acute  dermatitis,  which 
always  subsided  promptly.  The  almost  immediate  effect  of 
the  treatment  was  to  stop  the  pain  and  there  was  rapid  im- 
provement in  the  breast.  On  June  4,  one  month  after  beginning 
treatment,  the  ulcer  had  healed,  but  there  still  remained  in- 
durated nodules.  These  rapidly  disappeared  until  by  the 


REPORT   OF   CASES.  487 

middle  of  June  the  area  was  entirely  free  from  suspicious  points. 
The  scar  was  then  soft  and  movable. 

In  June  a  suspicious  disc-shaped  mass  was  discovered  in  the 
upper  part  of  the  left  breast  which  was  removed  by  a  radical 
operation  in  September. 

Case  83. — Mrs. ,  aged  fifty.    Six  years  ago  she  detected 

a  mass  in  the  left  breast  and  retraction  of  the  nipple,  and  the 
breast  was  subsequently  destroyed  by  several  series  of  treatments 
with  caustics.  Two  years  ago  a  similar  condition  developed 
on  the  right  side,  and  in  July,  1900,  this  was  removed  with 
caustics.  In  December,  1900,  the  patient  detected  in  the  scars 
evidence  of  recurrence  which  had  increased  up  to  the  time  she 
was  referred  to  me.  The  condition  when  she  came  to  me  is 
shown  in  figure  157.  The  scar  on  the  left  side  was  healthy 
looking  except  for  three  hazelnut-sized  nodules.  On  the  right 
side  the  scar  was  indurated  and  brawny  and  at  the  center  there 
was  an  irregular  indurated  ulcer  2J  by  1  inches.  There  was  no 
evidence  of  involvement  of  either  axilla.  Between  May  28 
and  July  14  the  patient  received  almost  daily  exposures  of 
moderate  intensity.  On  July  18  an  acute  vesicular  dermatitis 
was  produced,  and  the  exposures  were  discontinud  until  August 
6.  In  the  mean  time  the  dermatitis  subsided,  and  with  its 
disappearance  all  evidence  of  the  disease  vanished.  When  she 
returned  for  treatment  on  August  6,  all  nodules  had  disappeared 
and  both  scars  were  markedly  more  movable  than  before,  and 
the  feeling  of  contraction  in  the  chest-wall,  which  had  been  a 
source  of  discomfort  and  annoyance  to  the  patient,  was  very 
greatly  improved.  The  condition  since  that  time  is  shown  in 
figure  158. 

The  following  cases  are  all  cases  in  which  practically  a 
failure  occurred. 

Case  84. — Mrs. ,  aged  fifty.  In  1898  a  thorough  re- 
moval of  the  breast  was  done  by  Dr.  A.  J.  Ochsner,  and  the 
scar  remained  healthy  until  a  few  months  before  coming  to 
me,  when  an  ulcer  began  at  the  nipple  site.  At  the  time  of 
beginning  treatment  there  was  a  thick  mass  of  carcinomatous 
tissue  on  the  chest-wall,  closely  adherent  to  the  ribs,  with  a 
gangrenous  slough  at  the  center  as  big  as  a  silver  quarter. 


488        CARCINOMA    OF   THE    BREAST    AND    IN    THE    THORAX. 

The  supraclavicular  glands  were  markedly  involved.  Vigorous 
treatment  for  three  months  had  no  apparent  effect,  and  the 
patient  died  suddenly  as  a  result  of  involvement  of  the  lung. 

Case  85. — Mrs. ,  aged  fifty-two,  referred  to  me  by  Dr. 

Grey,  of  Chicago.  A  year  ago  the  left  breast  was  removed  by 
radical  operation  for  carcinoma.  There  was  a  prompt  re- 
currence, and  when  she  came  to  me  on  June  18,  1902,  there 
were  a  number  of  nodules  along  the  line  of  the  scar.  The 
tissue  along  the  border  of  the  pectoral  muscle  was  hard  and 
indurated.  There  was  a  hard  mass  of  nodules  in  the  left  axilla 
and  the  entire  left  arm  was  intensely  cedematous.  There  was 
a  hard  mass  above  the  clavicle.  The  patient  was  suffering 
much  pain  and  was  very  greatly  reduced  in  health.  Treatment 
in  this  case  was  continued  from  June  18  to  September  13,  with 
very  considerable  relief  of  pain,  and  with  almost  entire  dis- 
appearance of  the  oedema,  but  there  was  no  other  improvement. 
The  patient's  general  condition  grew  steadily  worse  until  treat- 
ment was  discontinued. 

Case  86. — Miss ,  aged  fifty-two,  referred  to  me  by  Dr. 

H.  R.  Chislett,  of  Chicago,  February  5,  1902.  A  year  before 
a  radical  operation  had  been  done  for  carcinoma  of  the  right 
breast.  When  she  came  to  me,  there  was  a  healthy  looking 
scar  from  the  axilla  to  the  median  line.  The  scar  in  the  axilla 
was  indurated  and  several  hard  glands  were  palpable  in  the 
axilla  and  there  were  two  large  hard  glands  above  the  clavicle. 
In  the  left  axilla  there  was  a  mass  about  the  size  of  an  olive. 
The  right  arm  was  oedematous.  The  patient  was  running  down 
rapidly  and  was  suffering  a  good  deal  of  pain.  This  patient  had 
vigorous  exposures  for  most  of  the  time  between  the  middle  of 
February  and  the  middle  of  June,  1902.  The  pain  was  relieved 
to  a  considerable  extent  and  the  glands  in  the  axilla  and  supra- 
clavicular  region  were  reduced  and  made  softer,  but  there  was 
no  other  effect  in  the  case,  and  the  patient  went  from  bad  to 
worse  until  the  treatments  were  discontinued. 

Case  87. — Mrs. ,  aged  fifty-four,  with  a  very  extensive 

ulcerating  recurrent  carcinoma  of  the  left  breast  and  involvement 
of  the  axillary  and  supraclavicular  contents.  She  had  vigorous 
exposures  for  a  month  without  any  practical  effect  except  relief 


489 


REPORT    OF    CASES.  491 

of  pain,  drying  up  of  discharge,  and  disappearance  of  odor, 
and  she  suddenly  died,  a  month  after  beginning  treatment, 
from  involvement  of  the  lung. 

Case  88. — Man,  aged  fifty-five,  referred  to  me  by  Prof.  D.  A.  K. 
Steele,  of  the  University  of  Illinois.  A  year  before  a  carcinoma 
of  the  right  breast  had  been  removed  by  radical  operation.  At 
the  time  of  coming  to  me  there  were  several  hard  nodules,  the 
size  of  a  hazelnut  and  smaller,  along  the  line  of  the  scar,  and 
in  the  axilla  there  were  several  indurated  glands.  There  was  a 
good  deal  of  pain.  Under  fairly  vigorous  x-ray  exposures,— 
thirty-three  in  all, — in  May  and  June,  1902,  the  nodules  all 
disappeared  from  the  scar  and  the  glands  in  the  axilla  became 
soft  and  hardly  palpable  and  his  pain  was  relieved.  The  im- 
provement was  so  great  that  in  July  he  thought  himself  cured, 
and  against  my  advice  quit  treatment.  November  1,  1902,  he 
died;  doubtless  of  metastatic  carcinoma,  although  I  have  not 
the  details. 

Case  89. — Mrs.  ,  aged  fifty.  A  carcinoma  of  the  left 

breast  was  removed  in  March,  1900,  by  radical  operation,  and 
a  recurrence  in  the  supraclavicular  glands  and  chest-wall  was 
removed  by  a  second  operation  six  months  later.  When  she 
came  to  me  on  January  18,  1902,  there  was  a  cancer  en  cuirasse 
involving  the  entire  left  chest-wall.  All  of  the  tissue  was  bound 
down  and  the  movement  of  the  chest  impeded.  The  axilla  con- 
tained a  dense  mass  of  indurated  glands  and  a  similar  immovable 
mass  existed  behind  the  clavicle.  The  arm  was  markedly 
redematous;  she  was  much  reduced  in  health  and  was  suffering 
much  pain.  Twenty-seven  vigorous  x-ray  exposures  in  January, 
February,  and  March,  1902,  had  no  effect  except  the  relief  of 
pain. 

Case  90. — Mrs. ,  aged  sixty-eight.  November,  1900,  a 

tumor  of  the  breast  was  removed  by  Dr.  C.  Fenger,  and  she 
first  noticed  a  recurrence  in  the  scar  in  January,  1902.  It  grew 
rapidly  and  soon  ulcerated,  and  was  very  painful.  When  she 
was  referred  to  me,  May  7,  1902,  there  was  a  dense  mass  of  car- 
cinomatous  tissue  occupying  the  entire  right  side  of  the  chest 
from  the  left  border  of  the  sternum  to  the  posterior  axillary 
line.  At  the  center  it  was  thrown  up  into  a  hard  nodular 


492    CARCINOMA  OF  THE  BREAST  AND  IX  THE  THORAX. 

mass  with  a  gangrenous  ulcer  in  the  center  an  inch  in  diameter. 
Treatment  for  a  month  and  a  half  had  no  effect  in  this  case 
and  the  patient  quit. 

Case  91. — Mrs. ,  aged  seventy,  with  a  cancer  en  cuirasse 

involving  the  entire  left  side  of  the  chest.  This  had  begun 
many  years  ago  as  a  tumor  in  the  breast  and  increased  slowly 
until  a  year  ago,  since  which  time  it  has  spread  rapidly.  When 
she  came  under  my  care,  January  20,  1902,  the  entire  left  chest- 
wall  was  covered  with  a  brawny,  hard,  purplish  inelastic  mass, 
which  rendered  that  side  of  the  chest  almost  immovable.  The 
induration  from  the  left  side  reached  beyond  the  median  line 
in  front  and  there  was  a  hard  nodular  mass  in  the  right  breast. 
The  axillary  and  supraclavicular  spaces  were  involved  and  the 
left  arm  was  enormously  swollen.  She  was  not  suffering  much 
pain,  but  suffered  great  distress  from  interference  with  breath- 
ing. She  had  twenty-one  vigorous  x-ray  exposures  between 
January  20  and  February  20,  1902,  with  no  apparent  effect. 
She  died  within  a  month  after  discontinuance  of  treatment. 

Summary. — In  the  above  list  of  eighteen  cases,  eight  cases, 
or  44.4  per  cent.  (Cases  74,  84,  85,  86,  87,  89,  90,  and  91),  showed 
practically  no  result  except  in  most  instances  marked  relief 
from  pain.  In  all  of  those  eight  cases  there  was  involvement 
of  the  supraclavicular  glands  at  the  beginning  of  treatment 
and  probably  intrathoracic  metastasis  as  well.  One  patient 
(Case  88)  was  relieved  of  the  evidence  of  carcinoma  locally, 
but  died  soon  after,  presumably  from  metastasis. 

The  remaining  nine  cases,  or  50  per  cent.,  show  results  that 
in  my  opinion  may  be  regarded  as  satisfactory.  One  of  these 
cases  (Case  75)  has  shown  almost  no  recurrence  at  the  original 
site  of  the  disease,  but  perhaps  has  carcinoma  of  the  spine.  In 
another  (Case  82)  carcinoma  developed  in  the  other  breast, 
which  was  removed  by  operation.  Another  case  (Case  76) 
showed  two  slight  easily  handled  recurrences,  but  the  patient, 
from  a  condition  of  helpless  invalidism,  has  been  restored  for 
a  year  to  fair  health.  In  Case  79  the  patient  is  not  relieved 
of  all  trace  of  carcinoma,  in  that  soft  glands  are  still  palpable, 
but  has  been  restored  to  good  health  and  the  disease  has  shown 
no  tendency  to  revive.  In  the  remaining  five  cases  (Cases  77, 


SUMMARY.  493 

78,  80,  81,  83)  there  is  symptomatic  cure.  In  one  case  (Case 
78)  there  is  cure  of  the  carcinoma  treated  by  x-rays  (Paget's 
disease),  but  it  is  by  no  means  certain  that  this  patient  will 
not  have  a  recurrence  of  the  carcinoma  of  the  other  breast, 
which  was  removed  surgically.  In  four  cases  (Cases  77,  80, 
81,  and  83)  there  is  symptomatic  cure  and  the  condition,  is  all 
that  could  possibly  be  hoped  for. 

The  failures  in  this  series  of  cases  may  readily  be  admitted 
and  still  the  method  of  treatment  be  amply  justified  by  the 
results.  It  is  surely  true  that  in  such  cases  as  these  there 
will  never  be  any  method  that  will  not  have  its  failures.  A 
more  unpromising  group  of  cases  could  hardly  be  imagined. 
Every  one  of  them  was  practically  beyond  relief  by  any  other 
method.  Most  of  them  had  been  refused  further  operative  pro- 
cedures and  had  no  outlook  left  except  pain  and  misery  and 
a  hopeless  illness.  If  in  the  whole  group  only  one  case  existed 
showing  such  results  as  are  seen  in  Cases  76,  77,  or  80,  for 
example,  the  method  would  seem  to  have  ample  justification 
for  its  use.  That  practically  50  per  cent,  of  the  cases  have 
had  relief  seems  as  good  a  showing  as  could  possibly  be  expected. 
The  cases  indicate  one  thing  strongly,  and  that  is  the  extreme 
importance  of  getting  the  patients  for  treatment  at  the  first 
evidence  of  recurrence.  It  is  then  that  there  is  a  fair  chance 
of  getting  them  well.  If  the  disease  is  allowed  to  go  on  until 
the  glands  behind  the  clavicle  and  within  the  thorax  are  in- 
volved, the  chances  for  relief  are  very  much  reduced. 

Primary  Carcinoma  of  the  Breast. — Case  92. — Miss  , 

aged  forty-five,  referred  to  me  by  Dr.  Wm.  J.  Mayo,  of  Rochester, 
Minn.  In  1900  her  attention  was  called  by  sharp  pains  in  that 
region  to  a  small  hard  mass  in  her  left  breast.  Since  that  time 
the  tumor  has  been  growing  steadily,  but  she  has  had  only  infre- 
quent pains.  Otherwise  she  has  been  in  good  condition.  At 
the  time  she  was  referred  to  me  there  was  a  hard  nodular  mass 
an  inch  and  a  half  in  diameter  in  the  left  breast,  movable  and 
not  tender.  The  nipple  was  retracted.  No  glands  were  palpable 
in  the  left  axilla.  This  patient  has  been  under  treatment  at 
intervals  since  April  8,  1902.  Up  to  August  18  she  had  ninety 
exposures,  and  she  then  had  no  further  exposures  until  November 


494        CARCINOMA    OF   THE    BREAST   AND   IN   THE    THORAX. 

6,  1902.  After  beginning  the  treatment  the  breast  became  con- 
siderably larger.  On  August  5  the  following  note  was  made: 
"Since  last  examination  of  breast,  July  31,  there  has  been  a 
notable  decrease  in  the  size  of  the  tumor,  which  is  now  about 
two-thirds  of  its  original  size."  August  19:  "Considerable  ery- 
thema over  breast.  Patient  says  the  breast  feels  quite  sore 
and  tender."  On  August  22  she  was  allowed  to  go  home,  as 
there  was  an  acute  vesicular  dermatitis,  and  she  did  not  return 
until  November  6.  At  the  time  of  her  return  the  retraction 
of  the  nipple  had  almost  disappeared  and  the  tumor  was  not 
more  than  one-third  its  original  size.  The  mass  in  the  breast 
is  hard  and  movable  and  of  regular  outline,  like  a  mass  of 
fibrous  tissue  rather  than  a  carcinoma.  The  patient's  general 
condition  is  considerably  improved. 

Case  93. — Mrs. ,  aged  seventy-six,  referred  to  me  by 

Dr.  A.  J.  Ochsner.  At  the  time  she  came  to  me,  June,  1901, 
there  was  a  tumor  the  size  of  an  orange  in  the  upper  and  outer 
quadrant  of  the  left  breast.  This  was  very  hard,  somewhat 
nodular,  adherent  to  the  skin,  and  only  slightly  movable. 
Several  glands  were  palpable  in  the  axilla.  This  patient  had 
vigorous  exposures  in  July  and  August,  1901,  with  the  pro- 
duction of  an  acute  dermatitis.  The  pain,  which  was  severe 
at  the  beginning,  was  entirely  relieved,  and  by  the  latter  part 
of  August  the  tumor  was  certainly  softer  and  somewhat  smaller ; 
but  the  patient  quit  treatment,  and  I  have  not  been  able  to 
get  trace  of  her  since. 

Case  94. — Mrs. ,  aged  sixty-six,  referred  to  me  by  Dr. 

Kearsle5r,  of  Chicago.  In  the  right  breast  there  was  a  hard 
disc-shaped  movable  mass  under  the  skin  two  inches  in  diameter. 
The  patient  had  had  occasional  shooting  pains  in  the  right 
breast  for  three  months,  but  the  mass  had  been  noticed  first 
a  few  weeks  before.  The  nipple  was  completely  retracted. 
There  were  a  number  of  hard  glands  the  size  of  a  lima-bean 
in  the  right  axilla.  The  patient  \vas  nervous  and  suffering  from 
lassitude  and  weakness.  This  patient  has  had  persistent  treat- 
ment, except  at  times  when  there  has  been  dermatitis,  from 
May  5  to  date,  having  had  up  to  November  10  one  hundred 
and  forty-nine  exposures.  At  the  present  time  the  mass  in  the 


PRIMARY    CARCINOMA    OF   THE    BREAST.  495 

breast  is  about  two-thirds  the  size  that  it  was  at  the  beginning 
of  treatment.  The  glands  in  the  axilla  are  soft  and  have 
hardly  been  palpable  since  the  middle  of  August. 

Case  95. — Mrs.  ,  aged  forty-five.  Four  years  ago  a 

small  lump  was  noticed  in  the  right  breast,  which  gradually 
enlarged  to  its  present  size.  During  the  last  year  it  enlarged 
more  rapidly  and  she  had  frequent  shooting  pains.  When  re- 
ferred to  me,  there  was  a  large,  hard,  nodular,  egg-sized  mass 
in  the  right  breast  and  retraction  of  the  nipple.  No  glands  are 
palpable  in  the  axilla.  This  patient  had  vigorous  exposures 
from  January  1,  1902,  to  May  9,  1902,— eighty-four  in  all,— 
with  the  production  at  the  last  of  an  acute  weeping  dermatitis. 
This  persisted  for  several  weeks,  during  which  time  there  was 
rapid  decrease  in  the  size  of  the  tumor.  Since  August  1  she 
reports  the  breast  has  been  apparently  normal;  the  mass  has 
disappeared,  the  breast  is  soft,  free  from  pain  or  tenderness, 
and  the  nipple  not  retracted. 

Case  96. — Miss ,  aged  forty-one,  referred  to  me  by  Dr. 

Y.  H.  Bond,  of  St.  Louis.  At  the  time  of  coming  to  me,  Decem- 
ber 12,  1901,  there  was  an  indurated  mass  in  the  left  breast — 
hard,  freely  movable,  irregular  in  outline,  and  about  two  inches 
in  diameter.  There  was  a  similar  but  smaller  mass  in  the 
right  breast,  somewhat  more  superficial,  nodular  and  movable. 
There  were  no  glands  palpable  in  the  axilla?.  The  nipples  were 
not  retracted.  Her  attention  was  first  called  to  her  breasts 
in  March,  1901,  by  the  fact  that  at  times  there  were  dull  aching 
pains  in  either  breast.  She  then  discovered  the  masses,  which 
she  thinks  have  increased  slightly  in  size  since  that  time.  She 
had  vigorous  x-ray  exposures  during  December,  1901,  and 
January  and  February,  1902.  The  exposures  were  discontinued 
on  account  of  dermatitis  the  first  of  March.  After  stopping 
treatment  the  dermatitis  was  quite  severe  for  two  months. 
When  she  returned,  August  27,  1902,  the  skin  was  still  somewhat 
red.  During  September  and  October  she  had  further  exposures, 
with  the  production  of  a  second  dermatitis,  on  account  of 
which  treatment  was  discontinued.  The  result  in  this  case  is 
about  the  same  as  in  Case  92.  There  is  considerable  diminution 
in  the  size  of  the  tumors,  but  they  have  not  disappeared. 


493        CARCINOMA    OF   THE    BREAST    AND    IN   THE    THORAX. 

Case  97. — Mrs.  ,  aged  sixty-five,  referred  to  me  by 

Prof.  E.  Wyllys  Andrews,  of  Northwestern  University,  January 
17,  1902.  When  treatment  was  begun,  she  had  an  indu- 
rated immovable  carcinoma  involving  the  entire  right  breast 
and  axillary  glands  and  the  supraclavicular  glands.  There 
was  also  metastasis  in  the  spine  and  probably  at  other 
points,  and  she  was  suffering  great  pain.  The  treatments  were 
given  with  the  hope  of  relieving  pain  without  any  expectation 
of  influencing  the  course  of  the  disease.  She  had  vigorous 
exposures  for  four  weeks,  and  after  that  irregular  exposures 
up  to  the  time  of  her  death,  two  months  after  beginning  treat- 
ment. A  dermatitis  was  produced  over  the  breast  at  the  end 
of  three  weeks.  The  relief  of  pain  was  prompt  and  marked, 
and  continued  to  the  end. 

With  the  production  of  the  dermatitis  over  the  breast  and 
in  the  axilla  there  was  a  rapid  disappearance  of  the  induration. 
The  breast  became  soft  and  the  evidence  of  carcinoma  entirely 
disappeared  in  that  location.  A  post-mortem  examination  was 
made  by  Dr.  J.  J.  Larkin,  who  reported  upon  the  case  to  Dr. 
Andrews  as  follows:  "The  tumor  of  the  breast  had  nearly  all 
disappeared;  skin  that  had  been  burned  by  the  rays  was  entirely 
restored.  The  enlarged  glands  under  the  arm  of  the  affected 
side  had  reduced  to  one-third  of  their  former  size." 

Case  98. — Mrs.  ,  aged  sixty,  referred  to  me  by  Dr. 

J.  B.  Murphy  and  Dr.  F.  S.  Hartman,  May  12,  1902.  She  had 
noticed  a  growth  in  the  breast  five  years  ago,  which  gradually 
increased,  and  during  the  last  year  grew  rapidly.  At  the  time 
she  "was  referred  to  me  there  was  in  the  right  breast  a  large 
hard  mass  which  was  adherent  to  the  skin.  There  was  a  puck- 
ered retraction  at  the  site  of  the  nipple.  Indurated  glands  in 
the  axilla  were  palpable.  She  had  recently  had  an  acute  gastric 
trouble,  but  at  the  time  of  coming  to  me  had  recovered.  This 
case  was  given  vigorous  exposures  from  May  12  to  July  17, 
and  a  slight  dermatitis  was  produced.  On  July  8  I  made  the 
memorandum:  "The  mass  in  the  breast  is  certainly  smaller." 
July  20  she  was  taken  with  an  acute  illness  and  I  did  not  see 
her  again.  On  August  20  Dr.  J.  B.  Murphy  wrote  me  as  follows : 
"I  saw  Mrs.  on  last  Fridav.  The  carcinoma  of  the 


SUMMARY.  497 

breast  has  entirely  disappeared,  but  she  is  suffering  from  a 
gastric  disturbance  from  which  I  fear  she  will  die."  She  died 
a  short  time  afterward  and  the  breast  was  obtained  for  examina- 
tion. Prof.  W.  A.  Evans,  of  the  University  of  Illinois,  examined 
it  and  informed  me  that  the  tumor  had  been  converted  into 
a  small  fibrous  mass  about  the  diameter  and  about  two-thirds 
the  length  of  an  index-finger.  It  was  a  hard  mass  of  fibrous 
tissue.  Microscopically  it  consisted  of  heavy  fibrous  tissue 
bands  with  a  few  islets  of  epithelium,  some  of  the  epithelium 
being  in  a  fair  state  of  preservation,  but  most  of  it  in  a  state 
of  advanced  retrogressive  change.  There  were  several  axillary 
glands  remaining,  about  one  centimeter  in  diameter,  the  epithe- 
lium of  which  was  in  a  fair  state  of  vitality.  The  mass  in  the 
breast  was  practically  scar  tissue.  The  epithelium  undergoing 
retrogressive  changes  showed  the  same  characteristics  that  I 
have  described  in  my  sections  and  that  other  observers  have 
described.  What  the  trouble  was  that  caused  her  death  Dr. 
Murphy  and  Dr.  Hartman  were  not  able  to  determine  before 
death,  and  post  mortem  only  a  partial  examination  of  the 
abdomen  was  permitted.  The  abdomen  was  opened  and  a 
superficial  examination  disclosed  no  carcinoma.  The  patient 
died  from  a  rather  acute  gastric  disturbance  lasting  about  six 
weeks,  in  which  the  most  important  symptom  was  persistent 
vomiting.  The  symptoms  seemed  to  point  to  an  intestinal 
obstruction  or  to  nephritis,  but  the  character  of  her  final  illness 
was  not  definitely  determined. 

These  two  cases  are,  of  course,  instructive  in  that  they  show 
conclusively  the  effect  of  x-rays  upon  carcinomatous  tissue  in 
the  breast. 

Summary. — This  group  of  seven  cases  of  primary  carcinoma 
of  the  breast  is,  of  course,  too  small  and  the  time  that  has 
elapsed  too  short  to  admit  of  deductions.  In  one  of  the  cases 
(Case  95)  there  has  been  a  symptomatic  cure.  In  the  only 
two  of  the  patients  that  have  died  (Cases  97  and  98)  the  masses 
had  become  impalpable  and  showed  only  a  small  mass  of  fibrous 
tissue  post  mortem.  In  these  three  cases  surgery  could  have 
done  no  more  than  rr-rays  did.  In  three  of  the  cases  (Cases 
92,  94,  and  96)  the  disease  has  been  checked.  In  one  (Case 

32 


498    CARCINOMA  OF  THE  BREAST  AND  IN  THE  THORAX. 

93)  there  was  no  result;  the  patient  quit  after  inadequate  treat- 
ment and  I  have  been  unable  to  trace  her.  Five  of  the  seven 
cases  were  referred  to  me  by  surgeons  and  presented  highly 
unfavorable  prospects  of  successful  surgical  removal.  It  may 
be  added  that  the  other  two,  one  of  which  has  been  sympto- 
matically  cured,  had  declined  operation. 

In  the  present  state  of  our  experience  with  x-rays  in  car- 
cinoma of  the  breast  I  believe  the  safe  position  is  to  advise 
operation  in  suitable  primary  cases,  and  I  have  persistently 
refused  to  take  such  cases  for  x-ray  treatment  except  where 
they  have  been  referred  to  me  by  men  whose  judgment  as  to 
the  question  of  operation  was  good,  or  where  the  physician  in 
charge  assured  me  that  the  patient  had  unequivocally  declined 
operation. 

I  have  treated  two  nondescript  cases  of  tumor  of  the  breast 
in  nervous  women. 

Case  99. — Mrs.  ,  aged  thirty-one,  referred  to  me  by 

Dr.  A.  J.  Ochsner,  March  7,  1902.  She  had  noticed  for  some 
time  lumps  in  either  breast.  At  the  time  she  came  to  me  there 
was  a  mass  in  the  left  breast  the  size  of  a  walnut,  not  very 
hard,  freely  movable,  and  somewhat  tender.  There  was  a 
similar  but  smaller  mass  in  the  right  breast.  There  were  two 
enlarged,  not  very  hard  glands  in  the  left  axilla.  She  com- 
plained of  a  good  deal  of  pain  in  either  breast.  She  was  given 
twenty-five  exposures  of  moderate  intensity  between  March  7 
and  July  26,  with  the  production  after  stopping  treatment 
of  an  acute  dermatitis.  The  pain  disappeared  soon  after  begin- 
ning treatment,  and  four  weeks  after  stopping  treatment  the 
indurations  in  the  breast  had  entirely  disappeared.  Since 
August  1,  1902,  both  breasts  have  been  free  from  induration 
or  pain.  The  axillary  glands  disappeared  under  similar  ex- 
posures. 

Case  100. — Mrs. ,  aged  forty.  At  the  time  she  was 

referred  to  me,  July  29,  1902,  there  was  below  the  nipple  in 
the  left  breast  a  disc-shaped  mass  about  an  inch  in  diameter. 
It  was  quite  superficial  but  was  not  attached  to  the  skin;  was 
not  very  hard  and  was  tender.  Her  attention  was  first  called 
to  it  a  short  time  before  by  shooting  pains.  There  were  no 


MEDIASTINAL   TUMORS.  499 

glands  palpable  in  the  axilla.  She  had  between  July  29  and 
October  2  twenty-seven  exposures  of  moderate  intensity.  By 
August  22  the  mass  was  markedly  smaller  and  the  shooting 
pains  had  disappeared.  By  September  25  the  mass  in  the 
breast  was  gone. 

Both  of  these  cases  were  symptomatically  cured.  Both  of 
them  may  have  been  carcinomata,  but  there  is  enough  uncer- 
tainty as  to  their  character  to  warrant  their  rejection  from 
any  list  of  carcinomata. 

Mediastinal  Tumors. — Case  101. — Mrs. ,  aged  fifty-six, 

referred  to  me  by  Dr.  J.  B.  Murphy,  of  Chicago,  April  23,  1902. 
Six  years  ago  the  left  breast  was  removed  for  carcinoma.  Eight 
months  before  I  saw  her  she  developed  hoarseness  and  pain 
in  the  chest.  At  the  time  she  was  referred  to  me  her  voice 
was  lost  and  there  was  a  large  bulging  tumor  under  the  sternum. 
There  were  hard  glands  in  the  left  supraclavicular  space.  She 
had  a  severe  cough  and  suffered  greatly  from  a  feeling  of  op- 
pression in  the  chest.  This  patient  had  twenty-nine  exposures 
between  April  24  and  June  20,  with  some  amelioration  in  her 
subjective  symptoms,  but  without  effect  on  the  tumor.  Since 
that  time  she  has  had  irregular  treatments  at  her  home  in 
another  city,  but  without  effect  except  in  keeping  her  com- 
fortable. 

Case  102. — Man,  aged  fifty,  with  a  history  of  a  small  lump 
beginning  low  down  behind  the  sternomastoid  muscle  about  two 
years  ago.  August  8, 1901,  the  mass  was  removed,  but  evidence 
of  recurrence  showed  almost  immediately,  and  a  second  operation 
was  done  October  29,  1901.  The  diagnosis  of  the  specimen  was 
"  a  carcinomatous  or  endotheliomatous  structure."  The  pathol- 
ogist found  it  impossible  to  make  a  more  definite  statement. 
The  disease  recurred  promptly  after  the  second  operation,  and 
between  December  21  and  January  21, 1902,  he  was  given  strong 
x-ray  exposures,  with  the  production  of  a  dermatitis,  the  relief 
of  pain,  and  some  evidence  of  diminution  in  the  tumor.  March 
22,  1902,  after  the  subsidence  of  the  dermatitis,  he  was  referred 
to  me.  At  that  time  there  was  an  extensive  swelling  on  both 
sides  of  the  neck,  hard  and  immovable,  and  extending  down 
behind  and  to  the  left  of  the  sternum.  The  patient  was  suffering 


500  CARCINOMA    OF   ESOPHAGUS. 

from  pain  and  from  sensations  of  distress  in  the  chest.  He  was 
given  vigorous  x-ray  exposures  daily  from  March  22  to  April 
23,  without  checking  the  progress  of  the  disease.  The  tumor 
gradually  spread  and  the  patient  died  from  its  effects  soon  after 
stopping  treatment.  Xo  result  except  the  relief  of  pain  occurred 
from  the  use  of  x-rays. 

Carcinoma  of  the  Esophagus. — Case  103. — Mr. .  aged 

sixty-five,  referred  to  me  April  4,  1902,  with  carcinoma  of  the 
esophagus  in  an  advanced  stage.  He  had  fort}'  exposures 
between  April  4  and  September  17,  with,  he  maintained,  con- 
siderable relief  of  pain  but  without  material  effect  on  the  progress 
of  the  disease,  from  which  he  died  in  November. 

Case  104. — Man,  aged  fifty-six,  referred  to  me  by  Prof.  W.  S. 
Halsted,  of  Johns  Hopkins  University,  May  7,  1902.  In  Sep- 
tember, 1901,  he  noticed  difficulty  in  swallowing.  Before  that 
time  he  had  lost  about  ten  pounds  in  weight,  and  between  that 
time  and  the  time  he  came  to  me  he  had  lost  about  ten  pounds 
more.  During  the  previous  eight  weeks  he  had  been  in  Balti- 
more, where  he  had  been  seen  by  Dr.  Halsted,  Dr.  Kelly. 
Dr.  Osier,  and  others,  and  an  obstruction  in  the  esophagus 
had  been  located  nine  inches  from  the  teeth.  At  first  a  clinical 
diagnosis  of  carcinoma  was  made.  Subsequently,  Dr.  Halsted 
informs  me,  a  piece  of  tissue  was  removed  through  the  esopha- 
goscope  and  the  diagnosis  of  adenocarcinoma  was  made  micro- 
scopically. At  the  time  he  came  to  me  his  physical  condition 
was  good.  There  was  a  good  deal  of  distress  and  some  pain 
in  the  chest  and  he  was  having  considerable  difficulty  in  swal- 
lowing, but  could  swallow  most  solids  after  very  thorough 
mastication.  Vigorous  x-ray  exposures  were  begun  over  the 
upper  part  of  the  chest  May  7,  1902,  and  from  that  time  to 
the  present  he  has  had  daily  exposures,  except  Sunday,  either 
over  the  chest  or  back,  the  exposures  being  changed  as  erythema 
developed.  There  was  prompt  disappearance  of  the  discomfort 
and  pain  in  the  chest  and  there  was  gradual — never  sudden- 
improvement  in  his  swallowing.  Six  weeks  after  beginning  the 
exposures,  without  making  any  changes  in  his  habits  of  life, 
he  had  gained  nine  pounds  in  weight,  his  pain  had  disappeared, 
and  he  was  having  no  difficulty  in  swallowing.  He  had  to 


CARCINOMA   OF   THE    ESOPHAGUS.  501 

masticate  thoroughly  but  could  eat  everything.  His  weight 
eventually  increased  fifteen  pounds.  Seven  months  after  be- 
ginning treatment  he  is  almost  at  his  normal  weight,  has  no 
pain,  swallows  without  difficulty,  feels  well,  and  is  vigorous. 


CHAPTER  XIII. 
DEEP-SEATED  CARCINOMA. 

Carcinoma  of  the  Head  and  Neck. — Three  cases  of  carcinoma 
of  the  lower  jaw,  in  none  of  which  did  any  improvement  take 
place,  have  been  reported  by  Johnson  and  Merrill.* 

Eijkman,t  on  the  other  hand,  has  reported  a  case  of  advanced 
carcinoma  of  the  root  of  the  tongue,  lower  jaw,  and  neck, 
which  under  x-rays  became  entirely  well;  also  a  case  of  cancer 
of  the  neck  in  which  further  growth  was  checked  by  treatment. 

I  have  treated  the  following  cases  of  carcinoma  of  the  head 
and  neck,  some  of  which  began  as  epitheliomata,  others  as 
more  deep-seated  lesions.  In  all  of  the  cases,  however,  except 
Cases  113  and  114,  there  were  at  the  time  treatment  was  begun 
deep-seated  metastases. 

Carcinoma  of  Neck. — Case  105. — Man,  aged  sixty-eight,  re- 
ferred to  me  by  Prof.  R.  R.  Campbell,  of  the  Chicago  Poly- 
clinic.  In  the  spring  of  1901  he  had  an  epithelioma  removed 
from  the  lower  lip,  with  rapid  recurrence  in  the  glands  of  the 
lower  jaw  and  neck.  A  radical  operation  was  done  in  June, 
which  was  followed  by  rapid  recurrence  of  the  disease  in  the 
supraclavicular  glands.  Dr.  J.  B.  Murphy  and  Dr.  Christian 
Fenger  saw  the  patient  in  September,  1901,  and  his  condition 
was  considered  inoperable. 

When  he  began  x-ray  treatment  there  were  tumors  on  either 
side  of  the  neck  above  the  inner  third  of  the  clavicle  as  large 
as  an  egg,  and  the  surrounding  tissue  was  infiltrated  with 
carcinoma.  He  was  put  under  x-ray  exposures  on  September 
26,  and  kept  under  daily  exposure  with  a  few  intervals — the 
longest  being  ten  days — for  three  months.  Within  a  month 
after  the  exposures  were  begun  and  at  the  time  that  dermatitis 
was  produced  there  was  very  marked  subsidence  of  the  tumors; 

*  American  Medicine,  1902,  iv,  p.  217. 
f  "Krebs  und  R.'jntgenstrahlen, "  Haarlem,  1902. 
502 


CARCINOMA   OF   NECK.  503 

they  disappeared  almost  entirely  and  remained  in  this  condition 
for  six  weeks.  After  an  interval  of  nearly  three  months  the 
case  was  seen  again  by  Dr.  Murphy,  on  December  3.  He  gave 
me  his  opinion  at  that  time  that  the  tumors  had  not  only  been 
checked  in  growth,  but  that  they  were  very  markedly  smaller 
than  when  he  had  seen  them  three  months  before.  Soon  after 
this,  however,  they  began  to  grow  rapidly,  and  the  patient 
would  undoubtedly  have  died  from  carcinoma  had  he  not  been 
taken  off  by  an  intercurrent  malady. 

In  this  case  we  were  hampered  by  the  fact  that  the  tissue 
transposed  in  the  plastic  operation,  which  was  very  extensive, 
was  quite  sensitive  to  the  x-rays  and  the  patient  was  unwilling 
to  have  the  full  effect  of  the  rays  produced. 

Case  106. — Man,  aged  fifty-five,  referred  to  me  by  Dr.  L.  L. 
McArthur,  who  had  removed  one-third  of  the  tongue  and  the 
sublingual  and  submaxillary  lymphatics  for  carcinoma.  Later  a 
manifestation  of  the  disease  occurred  in  a  lymphatic  near  the 
tip  of  the  styloid  process  involving  the  common  carotid  and 
the  jugular.  November  4,  1901,  these  lymphatics  were  removed 
and  the  sheath  of  the  vessels  cleared,  and  he  was  sent  to  me 
to  try  to  prevent  recurrence.  This  patient  was  given  exposures 
over  the  involved  area  almost  daily  from  November  25,  1901, 
to  March  23,  1902.  For  the  first  month  exposures  were  given 
cautiously  and  then  were  pushed  very  vigorously  to  the  point 
of  causing  a  severe  dermatitis,  but  the  exposures  were  never 
stopped  on  this  account.  There  was  never  any  evidence  that 
:r-rays  had  any  effect  upon  the  growth  of  the  tumor.  The 
entire  side  of  the  neck  became  involved  and  the  disease  caused 
the  patient's  death  a  short  time  after  stopping  treatment.  I 
was  never  able  to  convince  myself  that  any  effect  whatever 
was  produced  in  this  case  except  the  relief  of  pain.  That, 
however,  was  entirely  controlled,  so  that  the  patient  suffered 
practically  no  pain. 

Case  107. — Man,  aged  sixty.  This  case  is  very  similar  to 
Case  106,  except  that  there  was  very  extensive  ulceration  of 
the  tissues  in  this  case  and  almost  none  in  the  previous  .one. 
The  patient  was  operated  upon  by  Dr.  Butlin,  of  London,  for 
recurrent  carcinoma  in  the  neck  after  carcinoma  of  the  mouth; 


504  DEEP-SEATED    CARCINOMA. 

and  later  by  Dr.  Maurice  Richardson,  of  Boston.  In  order  that 
he  might  be  nearer  his  home,  he  was  referred  to  me  in  January, 
1901,  by  Dr.  Richardson  and  Dr.  F.  A".  Williams,  who  had 
been  giving  him  z-ray  exposures.  In  this  case  the  floor  of 
the  mouth,  the  neck,  and  the  lower  jaw  were  riddled  with 
carcinoma  and  the  patient's  condition  was  regarded  from  the 
start  as  almost  entirely  hopeless.  He  had  very  vigorous  ex- 
posures and  a  dermatitis  was  quickly  produced  and  maintained. 
Under  these  exposures  there  was  very  marked  subsidence  of 
the  tumors,  so  that  at  the  time  of  his  death  from  exhaustion 
three  months  after  beginning  treatment  all  of  the  nodules  of 
the  neck  had  disappeared,  the  normal  contour  of  the  neck 
was  restored,  and  some  healing  of  the  sinuses  had  taken  place. 
Altogether  the  subsidence  of  the  carcinomatous  tissue  has  been 
remarkable.  In  this  case  also  the  pain  was  controlled. 

Case  108. — Man,  aged  seventy-one,  referred  to  me  by  Dr.  A.  J. 
Ochsner,  writh  a  rapidly  growing  carcinoma,  the  size  of  a  fist, 
involving  the  right  angle  of  the  lower  jaw.  The  patient  con- 
tinued under  treatment  a  month  and  quit  after  there  had  been 
produced  considerable  softening  of  the  tumor. 

Case  109. — Man,  aged  seventy-one,  referred  to  me  by  Dr. 
George  F.  Bradley,  of  Chicago.  In  January,  1901,  an  epithe- 
lioma  was  removed  from  the  lip  by  a  V-shaped  incision,  and 
in  June,  1901,  Dr.  Nicholas  Senn  removed  part  of  the  lower 
lip  and  the  submaxillary  and  sublingual  lymphatics.  The  dis- 
ease recurred  promptly,  and  he  came  to  me  March  1,  1902,  with 
a  large  ulcerating  mass  of  carcinoma  under  the  chin  and  the 
glands  on  both  sides  of  the  neck  involved.  Under  x-ray  ex- 
posures the  pain  was  controlled  and  the  large  mass  under  the 
chin  almost  removed.  The  disease  continued  to  spread  in  the 
neck,  and  caused  the  patient's  death  three  and  a  half  months 
later.  The  only  practical  result  was  the  stopping  of  pain. 

Cose  110. — Man,  aged  forty-two;  referred  to  me  by  Dr.  A.  F. 
Jones,  of  Omaha,  Xeb.  This  case  is  almost  identical  in  all 
its  details  with  Case  107  above.  The  only  effect  of  x-rays 
was  the  reduction  of  large  masses  of  carcinoma  in  the  neck 
and  the  relief  of  pain,  but  the  disease  was  not  controlled  and 
the  man  died  of  hemorrhage. 


REPORT    OF    CASES.  505 

Case  111. — Man,  aged  sixty-eight.  In  this  case  there  was 
recurrent  carcinoma  of  the  lip  and  neck  after  epithelioma  of 
the  lip.  There  was  practically  no  effect  from  x-rays  except 
the  relief  of  pain  and  the  softening  and  disappearing  of  some 
of  the  masses. 

Case  112. — Man,  aged  fifty;  referred  to  me  by  Dr.  H.  V. 
Ogden,  of  Milwaukee,  with  a  primary  carcinoma  of  the  larynx 
and  enormous  carcinomatous  masses  on  either  side  of  the  neck. 
This  case  went  from  bad  to  worse  steadily  while  having  x-ray 
exposures,  which  had  apparently  no  effect  except  the  complete 
relief  of  pain.  The  relief  of  pain  in  the  case  was  striking. 

Case  113. — Man,  aged  forty-one,  referred  to  me  by  Dr.  W.  H. 
Fitch,  of  Rockford,  111.  In  January,  1901,  an  epithelioma  of 
the  lower  lip  was  removed  by  a  V-shaped  incision.  At  the 
same  time  the  submaxillary  lymphatic  glands  were  removed. 
In  March,  1902,  another  gland  was  removed  under  the  chin. 
At  the  time  that  he  came  to  me  the  lip  and  chin  were  healthy, 
but  there  was  an  indurated  gland  under  the  upper  sterno- 
cleidomastoid  muscle  with  some  palpable  nodules  near  the 
larynx.  Between  July  1  and  August  9  he  had  fairly  vigorous 
exposures  over  the  suspicious  areas,  with  the  production  of 
dermatitis  and  the  entire  disappearance  of  the  indurated  masses. 
Four  months  later  there  is  no  evidence  of  recurrence. 

Case  114. — Man,  aged  forty-five,  referred  to  me  by  Dr.  C.  M. 
Gleason,  of  Chicago.  A  year  and  a  half  ago  an  epithelioma 
was  removed  from  the  upper  lip,  the  submaxillary  contents 
being  cleaned  out  at  the  same  time.  Eight  months  later  a 
gland  was  removed  from  either  side  of  the  neck  about  the 
middle  third  of  the  sternocleidomastoid.  At  the  time  he  came 
to  me,  April  15,  1902,  the  scars  from  this  operation  showed 
several  small  growing  nodules,  and  the  scar  in  the  lip  con- 
siderable induration.  He  was  given  thirty  fairly  strong  x-ray 
exposures  over  these  areas  between  April  15  and  July  28,  1902, 
with  the  production  at  different  times  of  acute  dry  dermatitis. 
By  July  28  all  of  the  induration  had  disappeared.  The  scar 
in  the  lip  was  soft  and  movable  and  also  the  scars  in  the  neck. 
Four  months  later  there  is  no  indication  of  disease. 

Conclusions. — In  the  last  two  cases,   which   resemble  each 


506  DEEP-SEATED    CARCINOMA. 

other  closely,  a  symptomatic  cure  has  been  produced.  These 
were  both  cases  in  which  the  disease  was  relatively  superficially 
located.  In  all  of  the  cases  of  well-developed  deep-seated  car- 
cinoma in  the  neck  practically  no  effect  upon  the  course  of 
the  disease  can  be  shown.  Indeed,  in  my  experience  carcin- 
omata  of  no  other  class  have  shown  themselves  so  totally  un- 
affected by  vigorous  z-ray  exposures  as  the  deep-seated  car- 
cinomata  in  the  neck.  The  only  effect  that  can  be  claimed 
is  marked  relief  of  pain,  and  that  has  not  failed  to  result  in 
any  of  the  cases. 

Carcinoma  of  Mouth  and  Pharynx. — S.  Allen  *  has  reported  the 
treatment  of  a  carcinoma  of  the  tongue  with  no  relief  except 
of  pain. 

Brook  t  has  reported  an  epithelioma  of  the  lip  and  roof  of 
the  mouth  in  which  there  was  long  treatment  with  no  benefit. 

My  experience  in  this  group  of  carcinomata  covers  four  cases : 

Case  115. — Man,  aged  fifty-five,  referred  to  me  by  Dr.  0.  J. 
Stein,  of  Chicago.  A  year  and  a  half  ago  an  ulcer  developed 
on  the  inner  surface  of  the  left  cheek  just  behind  the  last  lower 
molar,  and  one  year  ago  was  removed.  At  the  time  he  was 
referred  to  me  there  was  a  healthy  scar  at  this  point,  but  in 
front  of  it  there  was  an  ulcer  the  size  of  a  little  finger-nail, 
with  indurated  nodular  border  and  evidently  an  epithelioma. 
There  were  large  patches  of  leukoplakia  on  the  tongue  and 
over  most  of  the  buccal  mucous  membrane.  There  was  on  the 
left  cheek  a  patch  of  thick  white  leukoplakia  extending  from 
the  ulcer  to  the  angle  of  the  mouth.  This  patient  was  given 
persistent  x-ray  exposures  to  the  point  of  producing  an  acute 
inflammation  of  the  mucous  membrane  on  several  occasions. 
Between  December  9,  1901,  and  October  24,  1902,  he  received 
144  exposures.  As  a  result  of  these  exposures  the  patch  of 
leukoplakia  on  the  inside  of  the  cheek  cleaned  up  and  was 
replaced  by  healthy  mucous  membrane,  but  there  was  no 
effect  on  the  epithelioma  and  it  has  gradually  spread.  It 
seems  hard  to  understand,  in  view  of  the  effect  on  lesions  of 
similar  character  situated  in  the  skin,  why  some  effect  was 

*  Boston  Med.  andSurg.  Jour.,  1902,  cxlvii,  p.  431. 
fBrit.  Med.  Jour.,  1902,  ii,  p.  1303. 


DEEP   CARCINOMA    IN   THE   ORBIT.  507 

not  produced  in  this  case.  The  metastases  in  the  neck  would 
not  have  been  expected  to  show  any  better  results  than  have 
been  found  in  other  lesions  in  the  same  location,  but  I  should 
have  expected  to  cause  some  effect  upon  the  lesion  in  the  mouth. 

Case  116. — Man,  aged  fifty-five,  with  an  epithelioma  on  the 
inner  surface  of  the  left  cheek  just  above  the  angle  of  the  mouth. 
The  lesion  was  as  large  as  a  silver  half-dollar  and  growing 
rapidly.  After  a  few  vigorous  exposures  without  effect  the 
mass  was  radically  removed,  but  the  disease  recurred  imme- 
diately in  the  cheek  and  neck,  and  he  was  given  subsequent 
exposures  for  a  month  without  effect,  when  he  discontinued 
treatment. 

Case  117. — Man,  aged  sixty-eight,  referred  to  me  by  Dr.  Chas. 
W.  Oviatt,  of  Oshkosh,  Wis.,  with  an  extensive  carcinoma 
involving  the  floor  of  the  mouth,  the  under  surface  of  the  tongue, 
and  the  submaxillary  lymphatics.  He  was  given  vigorous  ex- 
posures for  a  month  and  a  half  without  apparent  effect. 

Case  118. — Miss  ,  aged  twenty-eight,  with  carcinoma 

of  the  soft  palate  and  tonsil,  referred  to  me  by  Dr.  W.  S.  Hal- 
sted,  of  Baltimore.  This  patient  was  under  my  care  three 
months  without  apparent  effect  on  the  tumor,  and  she  dis- 
continued treatment. 

These  cases  must  all  be  put  down  as  failures,  and  they  simply 
add  their  weight  to  the  evidence  of  the  very  malignant  character 
of  deep-seated  growths  in  these  regions. 

Deep  Carcinoma  in  the  Orbit. — Case  119. — Man,  aged  sixty- 
two,  referred  to  me  by  Dr.  Wm.  H.  Wilder.  He  had,  for  several 
years,  an  epithelioma  of  the  lower  lip,  which  four  years  ago 
was  removed.  In  January  or  February,  1901,  an  epithelioma 
appeared  on  the  inner  side  of  the  orbit,  which  when  he  came 
under  my  care  had  developed  until  there  was  an  extensive 
carcinoma  involving  all  of  the  structures  in  and  around  the 
orbit.  The  growth  had  progressed  within  the  cranium  when 
treatment  was  begun,  and  he  was  suffering  harassing  pain. 
A  shrunken  eyeball  remained,  which,  before  beginning  treat- 
ment, Dr.  Wilder  removed.  Its  removal  in  no  way  lessened 
the  amount  of  pain  from  which  the  patient  was  suffering. 
He  was  given  vigorous  exposures  and  they  resulted  in  the 


508  DEEP-SEATED    CARCINOMA. 

prompt  relief  of  pain.  A  dermatitis  was  produced  at  the  end 
of  the  first  month,  and  with  its  appearance  the  tumor  mass 
shrank  considerably.  During  the  second  month,  however,  in 
spite  of  vigorous  exposures,  the  tumor  grew,  the  patient  devel- 
oped most  distressing  intracranial  pain,  and  there  was  every 
reason  to  believe  that  the  growth  was  developing  rapidly  in 
the  meninges.  The  case  seemed  to  have  gone  beyond  the  hope 
of  benefit,  and  when  the  disease  continued  to  show  symptoms 
of  aggressive  growth,  in  spite  of  the  production  of  an  acute 
dermatitis,  we  concluded  that  it  was  useless  to  give  him  ex- 
posures longer,  and  discharged  the  case  as  hopeless. 

The  subsequent  history  of  this  case  is  highly  interesting.  He 
was  discharged  the  latter  part  of  October,  1901,  and  I  heard 
nothing  further  from  him,  and  accordingly  in  the  report  of 
my  work  in  April,  1902,  I  reported  this  case  as  a  failure  and 
the  patient  presumably  dead.  On  April  30,  however,  almost 
six  months  after  his  discharge,  I  received  the  following  letter 
from  Dr.  T.  Sprague,  of  Sheffield,  111. : 

"  Dear  Doctor:  I  write  you  regarding  the  condition  of  Mr. 

,  an  old  gentleman  whom  you  treated  for  carcinoma 

of  the  right  eye,  discharged  as  incurable  (if  I  am  correctly 

informed  by  Mr. )  about  the  last  of  November.  He  was 

a  charity  patient,  and  I  think  was  referred  to  you  by  Dr.  Wilder. 
He  called  on  me  on  his  return  from  Chicago,  had  a  recipe  calling 
for  tablets  of  a  quarter  of  a  grain  of  morphin  to  be  taken  when 
in  pain.  I  saw  that  he  had  about  twenty  tablets.  I  noticed 
the  condition  of  his  eye  at  that  time,  and  concluded  from  my 
examination  that  it  was  only  a  question  of  time,  and  short 
time  at  that,  with  him.  I  saw7  him  yesterday  and  he  presents 
an  entirely  different  appearance.  The  mass  that  occupied  the 
orbit  has  shrunk,  allowing  the  lids  to  close.  He  is  free  from 
pain,  eats  and  sleeps  well,  uses  no  anodyne.  There  are  a  few 
little  nodules  on  the  nose  near  the  commissure  of  the  eyelids. 
AYith  that  exception  he  looks  quite  well.  He  has  certainly 
gained  since  coming  home,  and  I  feel  assured  it  is  the  result 
of  the  x-ray  treatment.  I  should  like  you  to  see  him  again." 

I  regret  that  Dr.  Sprague  and  I  have  both  been  unable  to 
get  a  report  later  than  April  30  upon  this  case,  but  even  granting 


CARCINOMA    IN   THE    ABDOMEN.  509 

that  the  disease  has  recurred  the  results  in  the  case  are  ex- 
tremely instructive.  There  was  surely  involvement  of  the 
intracranial  tissues  around  the  orbital  bones;  there  was  every 
evidence  of  the  greatest  malignancy  in  the  growth;  there  was  a 
mass  of  carcinoma  tissue  as  large  as  an  egg  in  the  orbit  and 
other  carcinomatous  tissue  beyond.  And  the  result  in  the  case 
leaves  no  doubt  of  the  deep-seated  effect  of  x-rays.  A  second 
instructive  fact  is  the  persistence  of  x-ray  effects.  An  acute 
dermatitis  had  caused  no  effect  on  the  tumor  at  the  time  of 
the  patient's  discharge,  but  the  x-ray  effects  were  sufficiently 
active  long  after  exposures  were  discontinued  to  cause  destruc- 
tion of  the  carcinomatous  tissue.  The  results  in  this  case  would 
seem  to  warrant  a  persistent  trial  of  x-rays  in  any  localized 
carcinoma,  no  matter  how  desperate. 

Carcinoma  in  the  Abdomen. — The  first  report  upon  the  thera- 
peutic use  of  x-rays  was  the  report  of  the  treatment  by  Des- 
peignes  *  of  a  carcinoma  of  the  stomach  improved  under  daily 
x-ray  exposures.  Skinner  f  has  reported  five  cases  of  intra- 
abdominal  tumor  treated  with  x-rays.  In  two  of  these  the 
growths  became  smaller,  and  in  two  others  constitutional  im- 
provement was  noticeable.  In  the  fifth  there  was  no  apparent 
effect.  Morton  J  has  reported  the  immediate  relief  of  pain  in  a 
case  of  carcinoma  of  the  stomach. 

I  have  treated  nine  cases  of  abdominal  carcinoma.  The 
length  of  treatment  in  these  cases  has  varied  from  only  a  week 
or  two  in  one  or  two  cases,  to  three  or  four  months  in  others. 
In  none  of  these  cases  is  it  positive  that  the  course  of  the  disease 
was  particularly  influenced.  Most  of  them  certainly  showed 
some  subjective  improvement,  and  when  there  was  pain  there 
has  been  reason  to  think  that  it  was  positively  affected;  but 
further  than  this  no  results  can  be  claimed.  These  cases  were 
of  the  usual  type  of  abdominal  carcinoma,  and  it  seems  hardly 
necessary  to  consume  time  in  an  analysis  of  them,  since  none 
of  them  furnishes  material  evidence  of  the  effect  of  x-rays. 

*Semaine  med.,  1896,  xvi,  p.  cxlvi. 

f  Rev.  Int.  d'Electrotherapie,  1902,  xii,  p.  28. 

JMed.  Record,  1902,  Ixi,  pp.  361,  801. 


510  DEEP-SEATED    CARCINOMA. 

Carcinoma  in  the  Pelvis. — Stuver  *  has  reported  a  case  of 
inoperable  carcinoma  of  the  uterus  in  a  woman  aged  forty- 
five,  in  which  there  was  severe  pain,  free  discharge,  and  ulcera- 
tion  of  the  uterus,  vagina,  and  rectum.  Pain  on  examination 
was  very  great.  Exposures  were  given  through  a  speculum. 
Under  daily  exposures  between  June  25  and  July  10,  1902, 
the  discharge  and  odor  decreased  very  much ;  the  sloughing  was 
arrested,  pain  was  relieved  so  that  opiates  \vere  no  longer 
necessary,  and  the  patient  so  gained  in  strength  that  she  was 
able  to  walk  without  any  assistance,  even  up  a  long  flight 
of  stairs.  Hett  f  has  reported  a  case  of  carcinoma  of  the 
cervix  extending  into  the  uterus  and  involving  the  vaginal  wall, 
in  a  woman  aged  forty-six.  Forty  exposures  had  been  given. 
The  pain  had  been  considerably  relieved,  but  beyond  that 
nothing  could  be  said.  Duncan  J  has  reported  benefit  in  one 
case  of  cancer  of  the  uterus,  as  have  Hopkins  §  and  C.  W. 
Alien.) 

I  have  treated  by  this  method  six  cases  of  carcinoma  in  the 
pelvis. 

In  the  following  two  cases  there  has  been  some  reason  to 
believe  that  a  positive  effect  of  x-rays  has  been  produced : 

Case  120. — Mrs.  ,  aged  fifty-two,  referred  to  me  by 

Prof.  E.  C.  Dudley,  of  Northwestern  University,  with  an  in- 
operable primary  carcinoma  of  the  uterus.  At  the  time  she 
was  referred  to  me  there  was  a  large  mass  of  carcinomatous 
tissue  involving  the  uterus  and  surrounding  parts,  and  there 
was  a  rather  free  purulent  discharge.  The  patient's  physical 
condition  was  fairly  good.  In  this  case  vigorous  x-ray  exposures 
have  been  given  from  May  28  to  date.  The  patient  has  had 
136  vaginal  exposures  in  addition  to  exposures  over  the  hypo- 
gastric  and  lumbar  regions.  This  patient  was  not  seen  by  Dr. 
Dudley  from  the  last  of  May  until  the  last  of  September — four 
months.  When  he  examined  her  the  second  time,  it  was  his 
opinion  that  the  mass  was  certainly  smaller,  and,  to  use  his 

*  Cincinnati  Lancet  Clinic,  1902,  N.  S.  xlix,  p.  151. 
f  Dominion  Medical  Monthly,  1902,  xix,  p.  76. 
t  Interstate  Medical  Jour.,  1902,  ix,  p.  531. 
§Phila,  Med.  Jour.,  1902,  ix,  p.  626. 
||  New  York  State  Jour,  of  Med.,  1902,  ii,  p.  176. 


CARCINOMA  IN  THE  PELVIS.  511 

expression,  "did  not  have  the  same  aggressive  character." 
There  has  been  no  ulceration  in  the  vagina,  there  has  been 
practically  no  discharge  for  several  months,  there  is  no  trouble 
with  the  bladder,  and  the  patient  has  remained  almost  free 
from  pain.  She  is,  however,  becoming  cachectic  and  running 
down  generally.  She  has  been  made  comfortable,  the  vaginal 
discharge  has  been  prevented,  the  course  of  the  disease  has 
perhaps  been  checked,  but  there  seems  little  reason  to  expect 
more. 

In  the  next  case  the  treatment  was  started  by  me,  but  has 
been  carried  out  entirely  by  Dr.  Winton. 

Case  121. — Mrs.  ,  aged  sixty,  referred  to  me  by  Dr. 

Charles  F.  Winton,  of  Washington,  Ind.  There  was  a  car- 
cinoma of  the  uterus  which  Prof.  L.  S.  McMurtry,  of  Louisville, 
Ky.,  had  decided  was  inoperable.  At  the  time  that  I  saw  her 
there  was  a  large  mass  of  carcinoma  in  the  pelvis  with  ulceration 
of  the  vaginal  wall  and  uterus,  and  with  a  profuse  discharge. 
The  patient  was  very  much  emaciated,  was  confined  to  her 
bed,  was  suffering  much  pain,  and  there  seemed  every  reason 
to  expect  a  quick  ending  of  the  case.  The  patient  was  seen 
by  me  March  2,  1902,  and  from  that  time  until  the  present, 
except  during  April,  when  she  had  a  lobar  pneumonia,  she  has 
had  on  an  average  six  x-ray  exposures  a  week.  Three  months 
after  beginning  exposures  there  was  marked  improvement  in  the 
patient's  condition.  The  discharge  from  the  vagina  had  almost 
stopped,  she  was  no  longer  confined  to  bed,  her  pain  had  practi- 
cally ceased,  and  in  every  way  she  was  very  much  better.  A 
very  marked  improvement  has  been  maintained.  In  a  letter 
of  November  28,  nine  months  after  beginning  treatment,  Dr. 
Winton  reports  upon  the  condition  of  the  case  as  follows:  "She 
is  in  fair  condition  to-day.  Has  some  little  discharge  occa- 
sionally, but  it  is  perfectly  free  from  odor."  She  has  been 
for  six  or  seven  months  practically  free  from  pain.  Any  opinion 
as  to  the  length  of  time  that  a  patient  with  pelvic  carcinoma 
may  live  is,  of  course,  uncertain;  but  it  is  surely  true  that  it 
would  have  been  thought  impossible  that  this  patient  could 
live  nine  months  when  x-ray  exposures  were  begun.  But  the 
prolonging  of  her  life  is  not  the  most  important  consideration. 


512  DEEP-SEATED    CARCINOMA. 

The  relief  of  pain,  the  checking  of  the  vaginal  discharge,  and 
the  consequent  comfort  to  the  patient,  are  at  least  of  as  great 
importance. 

In  the  four  following  cases,  little  besides  the  relief  of  pain 
can  be  claimed: 

Case  122. — Mrs. ,  aged  forty,  with  inoperable  carcinoma 

of  the  uterus,  with  profuse  vaginal  discharge,  and  suffering 
much  pain.  This  patient  had  exposures  during  two  months 
with  very  marked  relief  from  pain  and  decrease  of  discharge, 
but  without  further  effect,  and  one  month  after  stopping  treat- 
ment she  died. 

Case  123. — Mrs. ,  aged  forty,  with  extensive  recurrent 

carcinoma  in  the  pelvis,  and  all  through  the  abdominal  cavity. 
She  was  so  ill  as  to  be  expected  to  die  at  almost  any  time  when 
treatment  was  begun.  She  had  z-ray  exposures  daily  during 
November  and  December,  1901,  and  January  and  February, 
1902.  There  was  certainly  marked  subjective  effect  from  the  x- 
rays,  but  I  think  it  doubtful  that  it  was  more  than  a  psychic 
effect,  and  the  course  of  the  disease  was  not  materially  checked. 

Case  124. — Mrs.  ,  aged  forty-five,  with  extensive  re- 
current carcinoma  in  the  pelvis  and  abdomen.  This  patient 
had  a  month's  exposures  without  any  perceptible  effect. 

Case  125. — Mrs.  ,  aged  sixty,  with  a  large  mass  of 

recurrent  carcinoma  in  the  pelvis  and  abdomen.  She  was 
treated  for  a  short  time  by  me  and  later  by  the  physician  at 
her  home  without  apparent  effect  upon  the  course  of  the 
disease. 

In  two  of  the  above  cases  (Cases  120  and  121)  there  seems 
good  evidence  of  the  positive  effect  of  .r-rays.  At  any  rate, 
both  cases  have  pursued  much  more  favorable  courses  than 
was  expected.  Among  the  other  four  cases,  certainly  one  of 
them  (Case  123)  pursued  a  much  better  course  than  was  ex- 
pected, but  that  this  was  due  to  x-rays  is  doubtful.  In  all 
of  the  cases  there  was  some  amelioration  of  the  disease.  Pain 
was  lessened  and  the  vaginal  discharge  checked.  In  the  cases 
that  have  had  persistent  treatment  the  benefit  in  this  respect 
has  been  very  marked.  Ulceration  in  the  vagina  has  been 
overcome,  discharge  rendered  odorless  and  almost  entirely 


CARCINOMA    OF   THE   ANUS  AND    RECTUM.  513 

checked,  and  the  patients  freed  from  pain.  Such  benefits, 
of  course,  are  most  valuable  in  these  cases. 

Carcinoma  of  the  Anus  and  Rectum. — Bryant  *  has  reported 
the  case  of  an  old  man  with  a  cancerous  stricture  of  the  rectum, 
for  the  relief  of  which  colotomy  had  been  proposed.  He  was 
treated  with  the  x-rays,  through  the  perineum,  lying  on  his 
side  with  the  legs  flexed.  Great  relief  was  obtained,  to  the 
extent  that  the  patient  was  able  to  pass  feces  without  pain 
and  the  finger  could  be  passed  through  the  stricture  without 
difficulty.  Brook,f  on  the  other  hand,  has  reported  a  case  of 
cancer  of  the  rectum  in  which  the  sphincter  ani  was  incised  to 
allow  the  insertion  of  a  large  speculum,  through  which  treat- 
ment was  given  without  effect. 

I  have  treated  two  cases  of  carcinoma  of  the  rectum  and 
anus  by  this  method,  but  without  further  results  thus  far  than 
the  checking  of  discharge,  the  relief  of  pain,  and  some  shrinkage 
in  the  size  of  the  tumors. 

Case  126. — Man,  aged  thirty-five,  with  a  carcinoma  involving 
the  entire  perineum  and  the  anus,  was  under  treatment  for 
a  month,  with  drying  up  of  discharge,  considerable  relief  of 
pain,  and  shrinkage  of  the  tumor  masses. 

Case  127. — Mrs. ,  aged  fifty,  with  rapidly  growing  car- 
cinoma of  rectum  and  anus,  was  under  treatment  for  two 
months  with  effects  similar  to  those  in  the  preceding  case. 
A  radical  operation  was  then  performed.  This  I  believe  has 
not  given  material  benefit. 

In  neither  of  the  above  cases  was  the  treatment  more  than 
slightly  palliative,  but  in  neither  was  it  possible  to  carry  it 
out  effectively. 

*Brit.  Med.  Jour.,  1902.  ii,  p.  1302. 
tBrit.  Med.  Jour.,  1902,  ii,  p.  1303. 


33 


CHAPTER  XIV. 
SARCOMA  AND  OTHER  GRANULOMATA. 

Sarcoma. — The  literature  of  Rontgen  rays  contains  reports 
of  comparatively  few  cases  of  sarcoma  treated  by  this  method. 

Ricketts  *  reported  a  case  of  probable  melanotic  sarcoma  of 
the  chest-wall,  exposed  to  x-rays,  in  which  there  was  an  entire 
relief  of  pain  under  the  exposures  and  marked  shrinkage  of  the 
growth,  but  the  patient  subsequently  died  from  sarcoma.  Wil- 
liams f  has  reported  a  case  of  spindle-celled  sarcoma  of  the 
arm,  recurrent  after  operation,  which  had  had  exposures  twice 
a  week  for  from  twelve  to  twenty  minutes — fourteen,  in  all, 
at  the  time  of  report.  In  this  case  almost  all  of  the  induration 
has  disappeared,  the  swelling  has  subsided,  and  the  color  of  the 
skin  has  changed  from  red  to  normal.  Beck,|  of  New  York, 
has  reported  a  case  of  recurrent  melanosarcoma  of  the  thigh 
and  groin,  which  under  vigorous  x-ray  exposures  showed  marked 
checking  of  the  course  of  the  disease,  but  in  which  it  was  hardly 
possible,  in  Beck's  opinion,  to  expect  relief.  Kirby§  has  re- 
ported a  very  interesting  case  of  round-celled  sarcoma  treated 
successfully  by  x-ray  exposures.  The  patient,  a  man  aged 
sixty-four,  with  a  cancerous  history,  developed  after  a  trauma- 
tism  a  swelling  in  the  neck  which  remained  quiescent  for  sixteen 
or  eighteen  months.  After  a  severe  wrench  of  the  neck  it 
began  to  grow  rapidly  and  became  painful.  At  the  time  that 
the  case  came  under  observation  there  was  an  inoperable 
tumor  as  large  as  a  goose-egg,  firmly  fixed,  with  indurated 
borders  and  with  surface  dark  and  tense.  Soon  after  it  began 
to  ulcerate.  The  pain  was  most  severe.  Under  six  weeks' 
vigorous  treatment  the  tumor  disappeared,  the  surface  healed, 

*Jour.  Am.  Med.  Assoc.,  191)0,  xxxiv,  p.  76. 
f  "  The  Riintgen  Rays  in  Medicine  and  Surgery,"  p.  666. 
%  New  York  Med.  Jour.,  1901,  Ixxiv,  p.  906. 
\  Journal  of  Advanced  Therapeutics.  1902,  xx,  p.  89. 
514 


SARCOMA.  515 

pain  ceased,  and  the  patient  became  able  to  resume  his  work. 
The  case  was  symptomatically  cured. 

Seabury  Allen  *  has  reported  a  case  of  sarcoma  of  the  tonsil 
treated  by  x-rays,  with  shrinking  of  the  tumor  and  great  im- 
provement in  eating  and  talking,  but  without  complete  dis- 
appearance of  the  disease  at  the  time  of  report. 

Coley,t  in  a  recent  thoughtful  review  of  the  subject  of  the 
treatment  of  sarcoma  with  Rontgen  rays,  has  reported  upon 
ten  cases  of  sarcoma  which  he  has  treated  with  Rontgen  rays 
as  follows : 

Case  1,  small  round-celled  sarcoma  of  the  neck,  breast,  and 
axilla,  microscopic  diagnosis,  previously  treated  by  operation 
in  the  axilla  and  by  injection  of  toxins.  The  condition  on 
February  10,  1902:  "  Tumor  masses  encircled  entire  neck  from 
the  mastoid  process  to  the  clavicle  on  the  left  side;  on  the  right 
side  involving  the  entire  cervical,  supraclavicular,  pectoral,  and 
axillary  regions.  The  largest  protuberance  was  in  the  right 
cervical  region,  about  the  size  of  two  fists.  The  constriction 
of  the  trachea  was  so  great  as  to  cause  frequent  and  severe 
attacks  of  dyspnea."  With  four  or  five  exposures  per  week 
there  was  at  the  end  of  three  weeks  a  "marvelous  change." 
The  tumors  had  decreased  in  size  fully  one-third  and  had 
become  very  movable.  June  5  there  remained  on  the  left  side 
only  one  or  two  nodules  not  larger  than  peas;  on  the  right  side 
the  mass  as  large  as  two  fists  had  become  the  size  of  an  olive. 
There  was  a  small  nodule  the  size  of  a  hickory-nut  in  the  right 
axilla.  All  of  the  other  tumor  masses  had  entirely  disappeared. 
The  patient  had  entirely  recovered  her  general  health  and  took 
daily  walks  and  drives.  The  nodule  in  the  neck  was  removed 
and  found  still  to  show  the  typical  structure  of  a  round-celled 
sarcoma.  "The  patient  left  the  hospital  entirely  well,  July  8, 
1902." 

Case  2,  sarcoma  of  femur.  There  was  a  fusiform  enlarge- 
ment of  the  entire  lower  two-thirds  of  the  femur.  Under  a 
month  of  x-ray  exposures  the  tumor  decreased  an  inch  in  cir- 
cumference. On  the  discontinuance  of  treatment  for  two  weeks 

*  Boston  Med.  and  Surg.  Jour.,  1902,  clxvii,  p.  431. 
f  American  Medicine,  1902,  iv,  p.  251. 


516  SARCOMA    AXL>    OTHER   GRANULO.MATA. 

the  tumor  increased  an  inch.  When  treatment  was  resumed, 
the  tumor  decreased  two  inches  in  three  months.  The  patient 
was  losing  weight  and  there  was  evidence  of  metastases  in  the 
lungs. 

Case  3,  small  round-celled  sarcoma  in  the  pectoral  region. 
It  decreased  in  size  under  treatment  with  Coley's  fluid,  but 
with  x-rays  alone  for  two  weeks  there  was  no  visible  decrease. 
After  that,  under  toxin  injections  and  x-ray  treatment  com- 
bined, there  was  entire  recovery. 

Case  4,  round-celled  sarcoma  of  the  fascia  of  the  thigh,  was 
entirely  unaffected  by  x-ray  exposures. 

Case  5,  a  very  rapidly  growing  round-celled  sarcoma  of  the 
parotid.  Only  five  exposures  were  given,  and  there  was  no 
effect. 

Case  6,  a  recurrent  melanotic  sarcoma  of  the  iliac  glands. 
Under  x-ray  treatment  for  three  weeks  there  was  slight  diminu- 
tion in  the  size  of  the  tumors,  but  the  patient  was  steadily 
losing  weight. 

Case  7,  recurrent  spindle-celled  sarcoma  of  the  upper  jaw, 
involving  entire  right  superior  maxillary  region  and  extending 
into  the  roof  of  the  mouth  and  the  pharynx.  There  was  striking 
improvement  under  use  of  toxins.  Later  x-ray  exposures  were 
tried  for  three  weeks  with  no  noticeable  effect  either  on  the 
growth  of  the  tumor  or  on  the  pain. 

Case  8,  a  recurrent,  small  round-celled  sarcoma  of  the  gracilis 
muscle.  Under  a  month's  treatment  with  x-ray  exposures  alone 
the  tumor  did  not  increase  perceptibly.  Afterward,  under 
injection  of  streptococcus  cultures  and  toxins  combined  with 
x-ray  treatment,  the  tumor  at  first  decreased  but  later  increased. 

Case  9,  small  round-celled  sarcoma  of  the  back  following  a 
traumatic  hematoma.  The  tumor  disappeared  entirely  under 
three  x-ray  exposures  a  week  for  three  months. 

Case  10,  sarcoma  of  the  parotid.  An  irregular  protuberant 
tumor  ulcerating  at  several  points,  extending  from  the  orbit  to 
below  ramus  of  jaw  and  from  left  ala  nasi  to  mastoid  process. 
Under  x-ray  exposures  a  great  deal  of  the  tumor  at  first  sloughed 
away,  the  pain  decreased,  the  tumor  mass  steadily  shrunk  and 
became  less  vascular;  later  it  began  to  increase  under  the  angle 
of  the  jaw  and  the  use  of  toxins  was  begun. 


SARCOMA.  517 

In  addition,  he  reports  upon  four  other  cases  of  sarcoma 
treated  with  x-rays,  which  he  had  observed.  Case  1  was  a 
small  round-celled  sarcoma  of  the  neck  which  had  recurred 
six  times.  Under  treatment  with  mixed  toxins  there  was  slight 
temporary  benefit.  On  the  left  side  of  the  neck,  extending 
down  from  behind  the  ear,  there  was  a  large  tumor  the  size 
of  a  double  fist,  in  the  right  axilla  another  the  size  of  a 
goose-egg.  Under  x-ray  exposures  there  was  immediate  im- 
provement. In  four  weeks  the  masses  had  entirely  disappeared  ; 
though  exposures  were  made  only  over  the  neck,  the  axillary 
tumor  softened  within  three  or  four  weeks  and  eventually  it 
also  entirely  disappeared.  There  was  no  recurrence  four  months 
after  cessation  of  treatment. 

Case  2,  spindle-celled  sarcoma  of  abdominal  wall.  A  tumor 
the  size  of  a  cocoanut  in  scar  of  operation,  involving  abdominal 
muscles.  Temporary  benefit  from  toxins.  Under  x-ray  expo- 
sures the  patient's  general  health  had  greatly  improved,  but 
the  tumor  had  increased  slightly  in  size. 

Case  3,  recurrent,  small  round-celled  sarcoma  of  the  superior 
maxilla.  Temporary  improvement  under  the  use  of  toxins. 
Four  months'  treatment  under  x-rays  had  caused  a  marked 
decrease  in  size  of  the  tumor  and  decided  improvement  in  the 
patient's  condition. 

Case  4,  osteosarcoma  of  the  mastoid  and  temporal  bone. 
Toxins  had  been  used  with  some  benefit.  Under  x-ray  exposures 
there  was  immediate  and  almost  entire  relief  of  severe  pain. 
After  four  months  of  treatment  the  tumor  had  almost  disap- 
peared. 

Coley  comments  upon  his  cases  as  follows:  "While  none  of 
these  cases  can  as  yet  be  reported  as  a  cure,  they  nevertheless 
furnish  the  strongest  grounds  for  encouragement.  It  seems 
proved  that  in  a  certain  proportion  of  malignant  tumors  we 
have  found  an  agent  that  will  cause  the  disappearance  of  the 
growth  after  all  other  means  have  failed.  Whether  the  patients 
will  remain  well  sufficiently  long  to  justify  us  in  calling  them 
cured,  time  alone  will  tell.  The  entire  disappearance  of  a  large 
tumor  of  the  neck  in  four  patients — Skinner's,  of  New  Haven, 
Pusey's,  of  Chicago,  Fiske's,  of  Brooklyn,  and  my  own  case, 


518  SARCOMA    AND    OTHER   GRANULOMATA. 

of  much  more  extensive  round-celled  sarcoma  of  both  sides  of 
the  neck,  clavicular  and  axillary  regions  (the  diagnosis  of  sar- 
coma being  confirmed  in  every  .case  by  competent  pathologists)— 
gives  us  great  cause  for  congratulation.  When  we  consider 
how  large  a  proportion  of  sarcomas  have  their  origin  in  the 
neck,  and  how  hopeless  they  have  proved  to  operative  treatment, 
we  realize  the  importance  of  these  recent  observations.  .  .  . 
I  have  never  yet  seen  a  case  of  sarcoma  of  the  neck  cured  by 
operation,  nor  have  I  been  able  to  find  an  authentic  case  re- 
ported by  other  surgeons ;  hence,  if  in  the  x-ray  we  have  a  means 
of  destroying  these  growths,  or  a  certain  proportion  of  them, 
it  means  a  great  advance  over  present  methods." 

I  have  treated  with  x-rays  eleven  cases  of  sarcoma. 

Case  128. — Man,  aged  twenty-four,  referred  to  me  by  Dr. 
A.  J.  Ochsner,  September  2,  1901.  In  February,  1901,  he 
noticed  a  hard  swelling  behind  the  angle  of  the  jaw,  two  inches 
below  the  ear  on  the  left  side  of  the  neck,  which  gradually 
increased  in  size.  In  May  a  similar  hard  swelling  appeared 
on  the  right  side  of  the  neck,  and  this  rapidly  increased.  By 
August  there  had  developed  large  immovable  swellings  on 
either  side  of  the  neck,  the  size  of  a  fist,  and  he  then  consulted 
Dr.  Ochsner.  Dr.  Ochsner  made  a  diagnosis  of  sarcoma,  and 
on  August  19  removed  the  tumor  on  the  left  side  of  the  neck. 
The  microscopic  examination  of  the  tissue  was  made  by  Prof. 
F.  R.  Zeit,  of  Northwestern  University,  who  made  a  diagnosis 
of  round-celled  sarcoma.  Two  weeks  after  the  operation  on 
the  left  side  of  the  neck  Dr.  Ochsner  sent  him  to  me  to  have 
x-ray  exposures  given  while  he  was  getting  in  condition  to 
have  the  operation  on  the  other  side.  At  that  time  there  was 
a  healthy  scar  on  the  left  side  of  the  neck  and  a  large  swelling 
on  the  right  side,  as  shown  in  figure  159.  This  was  a  hard, 
diffuse,  immovable  tumor,  and  involved  so  much  tissue  that 
the  neck  was  rigid.  He  was  given  vigorous  x-ray  exposures 
and  the  tumor  mass  began  to  subside  immediately.  At  the  end 
of  four  weeks  an  acute  vesicular  dermatitis  was  caused,  and 
by  that  time  the  tumor  had  entirely  disappeared,  as  shown 
in  figure  160..  In  four  weeks  the  circumference  of  his  neck 
had  decreased  from  17^  inches  to  14  inches.  The  only  trace 


Fig.    159. — Primary    sarcoma    of    the 
neck.     Case  128. 


Fig.  160. 


Fig.  161. — Case   128.     Recurrence   on 
both  sides  of  the  neck. 


Fig.  162. 


519 


REPORT    OF    CASES.  521 

left  of  the  tumor  was  a  gland  over  the  middle  of  the  sterno- 
cleidomastoid  muscle  not  larger  than  an  almond  kernel.  As 
soon  as  the  tumor  disappeared  he  discontinued  treatment,  against 
my  protest.  After  stopping  treatment  the  first  of  October,  the 
dermatitis  promptly  subsided,  and  without  further  treatment 
there  was  no  evidence  of  return  of  the  disease  until  March  1, 
1902 — five  months.  The  first  of  March  he  discovered  the  devel- 
opment of  a  hazemut-sized  nodule  under  the  angle  of  the  right 
lower  jaw,  and  at  the  same  time  a  similar  growth  on  the  left 
side  of  the  neck.  These  rapidly  grew,  but  he  did  not  return 
for  treatment  until  March  31.  When  he  returned  March  31, 
there  were  large  tumor  masses  on  either  side  of  the  neck,  the 
chain  extending  from  the  mastoids  to  the  clavicles.  (See  Fig. 
161.)  They  were  very  hard  and  many  of  them  not  movable. 
It  is  an  interesting  fact  that  the  recurrence  on  the  left  side 
of  the  neck,  which  had  been  treated  surgically,  was  greater 
than  upon  the  right.  He  was  given  vigorous  exposures  on  both 
sides  of  the  neck  for  five  weeks,  from  March  31,  1902.  The 
tumors  in  the  neck  disappeared  entirely  and  never  afterward  re- 
turned (Fig.  162).  He  again  discontinued  treatment  against  my 
protest.  Six  weeks  later  he  returned.  There  was  no  recurrence 
on  the  outside  of  the  neck,  but  there  was  a  swelling  the  size 
of  a  small  egg  in  the  right  tonsil,  which  was  causing  some  diffi- 
culty in  swallowing,  and  numerous  small  nodules  were  present 
in  the  skin  or  just  under  the  skin  on  many  parts  of  his  body. 
From  June  19  he  was  given  vigorous  exposures  over  the  various 
tumors  that  developed.  The  tumor  of  the  tonsil  and  numerous 
subcutaneous  tumors  disappeared.  After  he  began  treatment 
many  new  subcutaneous  tumors  developed,  and  between  the 
middle  of  June  and  the  middle  of  September  a  great  number 
of  these  disappeared  under  x-rays.  During  this  time  he  was 
rapidly  running  down,  and  the  latter  part  of  September  symp- 
toms of  brain  tumor  developed  and  the  patient  rapidly  went 
from  bad  to  worse. 

The  physical  condition  of  this  patient  when  he  first  came 
under  my  care  in  September,  1901,  was  getting  bad  and  he 
was  suffering  considerable  pain.  With  the  relief  which  he  got 
in  September,  1901,  and  again  in  April,  1902,  his  physical  con- 


522  SARCOMA    AXD    OTHER    GRAXULOMATA. 

dition  began  to  pick  up  very  much  and  his  pain  disappeared. 
Indeed,  he  felt  so  well  after  each  of  these  treatments  that  he 
could  not  be  convinced  that  it  was  necessary  for  him  to  stay 
longer  from  his  work,  so  that  it  was  impossible  to  give  him 
as  thorough  treatment  as  I  felt  sure  at  that  time  was  necessary. 
It  is  perhaps  probable  that  this  patient  would  have  had  metas- 
tases  no  matter  how  thoroughly  the  lesions  in  the  neck  might 
have  been  treated,  but  it  is  impossible  to  avoid  feeling  that 
had  I  been  able  to  continue  the  persistent  treatment  of  this 
case  as  I  desired  the  disease  might  have  been  eradicated. 
Nothing  could  have  proved  more  susceptible  than  these  tumors 
to  x-rays.  Certainly  there  seems  good  reason  to  believe  that 
the  chance  of  their  eradication  would  have  been  as  good  as  the 
chance  of  permanent  cure  after  operation  upon  any  sarcoma. 

Case  129. — Man,  aged  sixty-seven,  osteosarcoma  of  the  right 
shoulder,  with  symptoms  of  sarcoma  of  the  bladder.  There  was 
profound  cachexia  and  evidence  of  general  sarcomatosis.  The 
patient  was  put  under  x-ray  exposures,  chiefly  with  the  hope 
of  relieving  his  pain.  He  was  given  sixteen  exposures  without 
effect  upon  the  tumor,  but,  according  to  his  voluntary  statement, 
with  considerable  relief  from  pain.  With  my  approval  the  treat- 
ment was  discontinued. 

Case  130. — Woman,  aged  sixty,  with  extensive  inoperable 
sarcoma,  involving  the  right  pectoral  muscles  and  shoulder. 
She  had  treatment  for  a  month,  with  marked  relief  from  pain 
according  to  her  voluntary  statement,  and  in  the  opinion  of 
her  physician,  Dr.  William  Fuller,  but  without  further  effect. 

Case  131. — Child,  aged  four  years,  referred  to  me  by  Dr. 
Charles  F.  Roan,  of  Chicago.  In  January,  1902,  a  tumor  the 
size  of  half  an  apple  was  discovered  under  the  vastus  externus 
of  the  left  leg,  and  was  removed  by  radical  operation  in  April. 
Diagnosis  of  sarcoma,  or  infected  granuloma,  was  made  by 
Professor  Zeit,  of  Northwestern  University.  Almost  imme- 
diately after  the  operation  another  tumor  the  size  of  a  walnut 
was  found  under  the  external  oblique.  It  grew  rapidly  and 
was  removed  by  another  operation  July  2,  1902.  At  the  time 
she  was  referred  to  me  there  was  a  large  tumor  which  began 
in  the  cicatrix  of  the  second  operation,  and  had  rapidly  grown 


SARCOMA    OF   PAROTID.  523 

until  it  occupied  the  lower  half  of  the  anterior  abdominal  wall. 
The  abdominal  wall  was  greatly  thickened,  the  skin  was  in- 
volved over  almost  the  entire  extent  of  the  tumor,  and  the 
tumor  was  immovable.  The  left  leg  was  enormously  swollen. 
There  was  also  a  tumor  the  size  of  a  goose-egg  that  had  recurred 
in  the  scar  of  the  left  leg.  The  child  was  cachectic  and  running 
down  rapidly,  had  no  appetite,  and  suffered  intense  pain. 
Vigorous  daily  exposures  were  begun  on  September  1,  1902, 
with  almost  immediate  relief  of  pain.  In  ten  days  there  was 
a  perceptible  shrinking  of  the  tumor,  the  appetite  was  better, 
she  was  sleeping  better  than  she  had  for  months,  and  looked 
very  greatly  improved.  The  exposures  were  carried  to  the 
point  of  producing  an  acute  vesicular  dermatitis  at  the  end 
of  a  month,  by  which  time  the  tumor  in  the  abdominal  wall 
had  almost  entirely  disappeared.  Until  the  middle  of  October 
the  general  improvement  was  maintained,  but  it  was  evident 
that  the  disease  was  spreading,  and  on  November  8  the  child 
died  from  general  sarcomatosis.  The  gain  in  this  case  was  the 
relief  of  pain,  which  was  permanent  and  very  marked,  and  the 
temporary  improvement  in  the  child's  physical  condition. 

Sarcoma  of  Parotid. — Case  132. — Mrs. ,  aged  forty-nine, 

referred  to  me  by  Dr.  A.  J.  Ochsner,  on  April  22,  1902,  with 
the  following  history:  For  a  year  past  she  had  been  having 
pain  in  the  right  ear  and  in  the  right  temporo-maxillary  articu- 
lation. For  three  months  past  this  had  been  of  most  harassing 
character.  Three  months  before  I  saw  her  a  hard  swelling  had 
developed  in  front  of  the  right  ear  and  rapidly  increased  in 
size.  When  she  came  to  me  there  was  a  hard  nodular  mass 
in  front  of,  below,  and  behind  the  right  ear,  extending  deep 
into  the  neck,  and  immovable.  The  whole  mass  was  as  large 
as  a  fist  and  formed  a  conspicuous  tumor.  In  the  side  of  the 
neck  below  the  tumor  there  were  a  number  of  enlarged  indurated 
glands.  From  pain  and  loss  of  sleep  the  patient's  condition 
was  much  reduced.  She  had  been  seen  by  Dr.  Ochsner,  Dr. 
Senn,  and  Dr.  Fenger,  and  it  had  not  been  deemed  advisable 
to  operate. 

She  was  put  under  strong  x-ray  exposures  on  February  26, 
1902,  and  between  that  date  and  April  10  she  received  thirty- 


524  SARCOMA    AND    OTHER    GRAXULOMATA. 

four  exposures  without  the  production  of  a  marked  dermatitis. 
On  March  20,  after  seven  exposures  (she  had  not  received  more 
because  she  was  physically  unable  to  come  for  treatment),  the 
following  note  was  made:  ''Tumor  a  little  softer,  slept  well  last 
night;  not  nearly  as  much  pain  as  previously."  On  March  31, 
the  patient  having  had  vigorous  exposures  on  alternate  days 
since  March  20,  it  was  noted  that  "there  is  not  nearly  so  much 
pain.  Tumor  is  smaller."  From  April  1  to  May  10  she  had 
strong  exposures  almost  daily.  At  that  time  she  was  taken 
acutely  ill  with  what  was  called  neuralgia  of  the  stomach,  and 
she  had  no  further  treatment  for  six  weeks.  When  she  re- 
turned, June  15,  she  reported  that  she  had  had  almost  no  pain 
until  within  the  last  week,  and  the  tumor  had  almost  entirely 
disappeared.  There  was  no  visible  swelling  and  the  only  indu- 
ration left  was  a  small  mass  the  size  of  an  almond  below  the 
ear.  From  June  23  until  the  present  she  has  had  treatment 
more  or  less  regularly,  having  had,  up  to  November  12,  46 
exposures.  The  tissues  have  been  kept  markedly  pigmented 
but  there  has  been  no  acute  dermatitis.  There  has  been  no 
evidence  of  return  of  the  mass.  There  is  now  no  tumor  apparent 
and  no  induration  to  be  found.  All  of  the  glands  in  the  neck 
also  have  disappeared.  There  has  been  practically  no  pain  in 
this  region  since  the  disappearance  of  the  tumor,  five  months 
ago.  The  patient  still  has  pain  in  the  left  side  of  the  abdomen 
just  below  the  border  of  the  ribs,  but  no  tumor  is  demonstrable. 

Case  133. — Mrs.  ,  aged  sixty-five.     Sixteen  years  ago 

a  tumor  of  the  tonsil  was  removed,  which  on  microscopic  exam- 
ination proved  to  be  a  round-celled  sarcoma.  Seven  years  ago 
a  small  swelling  appeared  in  front  of  the  ear,  and  another  below 
and  behind  it.  They  remained  about  the  size  of  a  filbert  and 
movable  until  August,  1901,  when  they  began  to  grow  rapidly. 
At  the  time  she  was  referred  to  me  there  was  a  tumor  in  front 
of  and  below  the  ear  larger  than  a  fist,  consisting  of  three  masses 
that  had  become  confluent.  They  were  densely  hard  and  immov- 
able, the  patient  was  suffering  a  good  deal  of  pain,  and  there 
was  paralysis  of  the  facial  nerve.  This  patient  had  vigorous 
x-ray  treatment  in  May,  June,  July,  and  August;  receiving,  in 
all,  65  exposures.  There  was  slight  shrinkage  in  the  tumor 


REPORT  OF   CASES.  525 

temporarily,  but  its  course  was  not  markedly  checked  and  the 
patient  died  from  its  effect  September  18,  one  month  after 
stopping  treatment.  There  was  marked  relief  from  pain  in  this 
case,  but  no  other  effect. 

Case  134. — Mrs.  ,  aged  thirty-five.  In  April,  1901,  a 

tumor  the  size  of  a  hazelnut  was  discovered  in  the  right  axilla, 
which  by  September,  1901,  had  increased  to  the  size  of  a  large 
walnut,  and  was  removed.  On  examination  it  proved  to  be  a 
small  round-celled  sarcoma.  When  she  was  referred  to  me, 
April  22,  1902,  the  scar  was  healthy,  but  there  were  two  large, 
hard,  supraclavicular  glands  and  two  nodules  in  the  abdominal 
wall,  one  the  size  of  a  hazelnut,  the  other  the  size  of  a  pea, 
both  of  them  quite  hard.  Her  physical  condition  was  not  good; 
she  was  very  anemic,  had  no  appetite,  and  was  having  night- 
sweats.  For  three  months  she  had  vigorous  exposures  over  this 
area,  with  the  production  at  several  times  of  an  acute  dermatitis. 
All  of  the  nodules  gradually  became  smaller,  so  that  by  July 
28  the  masses  had  entirely  disappeared.  There  was  continuous 
improvement  in  her  general  condition,  her  appetite  became  good, 
she  became  much  stronger,  and  the  night-sweats  ceased.  This 
was  her  condition  when  treatment  was  discontinued,  August  1, 
1902.  This  is  a  case  in  which  there  is  every  reason  to  expect 
metastases  in  other  parts,  but  the  effect  upon  the  lesions  at 
the  time  she  was  under  treatment  was  all  that  could  have  been 
desired. 

Case  135. — Mrs. ,  aged  sixty-two,  with  enormous  osteo- 

sarcoma  of  the  shoulder,  which  had  been  developing  since  an 
injury  three  years  and  a  half  ago.  This  patient  had  vigorous 
x-ray  exposures  at  my  hands  from  February  19,  1902,  to  June 
17,  1902,  without  material  effect  upon  the  size  of  the  tumor. 
There  was,  however,  marked  relief  of  pain.  She  was  suffering 
harassing  pain  previous  to  the  beginning  of  x-ray  exposures, 
and  this  was  in  great  part  stopped  by  the  treatment. 

Case  136. — Man,  aged  forty,  referred  to  me  by  Dr.  W.  B. 
Fiske  and  Dr.  L.  L.  McArthur,  of  Chicago,  September  22,  1902. 
Six  months  ago  he  noticed  a  painful  lump  on  the  left  side  of 
the  breast.  It  grew  very  slowly  until  the  last  month,  when 
it  rapidly  extended.  At  the  time  he  was  referred  to  me  there 


526  SARCOMA    AND    OTHER    GRAXULOMATA. 

was  a  large  tumor  mass  occupying  the  whole  front  of  the  chest 
between  the  anterior  axillary  lines  on  either  side  and  from 
the  manubrium  of  the  sternum  to  the  ensiform  cartilage.  It 
was  densely  hard,  of  purplish  color,  and  involved  the  skin. 
There  were  indurated  nodules  in  either  axilla.  Over  the  center 
there  were  a  few  small  ulcerating  points.  He  had  moderate 
pain.  A  piece  of  this  tissue  was  taken  for  microscopic  examina- 
tion, but  unfortunately  it  was  never  possible  to  get  a  satis- 
factory report  upon  it.  The  only  part  that  the  pathologist 
got  was  the  overlying  skin.  Clinically  there  was  every  reason 
to  believe  that  it  was  sarcoma.  It  is  hardly  possible  that  it 
was  a  syphilitic  gumma;  the  patient  had  no  history  of  syphilis 
and  had  no  anti-syphilitic  treatment  while  under  x-ray  expos- 
ures. The  mass  was  over  a  foot  in  diameter  and  three  inches 
thick  at  the  center,  almost  without  ulceration,  and  bore  no 
clinical  resemblance  to  a  syphilitic  gumma. 

This  patient  was  put  under  vigorous  daily  x-ray  exposures 
September  23,  and  the  effect  was  little  short  of  marvelous.  By 
September  29  the  ulcers  had  dried  up  and  were  healed  over 
and  the  circumference  of  his  chest  had  decreased  an  inch.  On 
October  6  there  was  marked  diminution  in  the  size  of  the  tumor. 
He  was  feeling  much  better  and  his  pain  was  much  diminished. 
After  this  the  improvement  was  continuous.  On  November  1 
the  tumor  mass  had  entirely  disappeared  from  the  chest-wall, 
the  normal  contour  was  restored,  and  the  glands  had  disap- 
peared from  the  axilla.  The  only  trace  of  the  tumor  left  was 
slight  oedema  over  the  lower  part  of  the  sternum.  The  im- 
provement has  been  maintained.  At  no  time  has  more  than 
a  slight  erythema  been  produced.  The  case  seemed  so  hopeless 
when  treatment  was  begun  that  I  failed  to  photograph  it,  but 
some  idea  of  the  change  in  the  condition  may  be  gained  from 
the  difference  in  chest  measurements  at  different  times.  The 
circumference  of  the  chest  at  the  nipple  line,  on  full  expiration, 
was  as  follows : 

September  23 38i  inches. 

October  1 37*  inches. 

October  6 35]  inches. 

October  17 34    inches. 


o  2 


507 


REPORT    OF    CASES.  529 

The  change  in  this  case  can  hardly  be  overstated.  It  is  ex- 
tremely unfortunate  that  the  diagnosis  of  sarcoma  in  the  case 
cannot  be  confirmed  microscopically,  but  the  clinical  diagnosis 
was  made  by  Dr.  McArthur  and  Dr.  Fiske,  and  there  is,  I 
believe,  almost  no  room  for  doubt  upon  that  point.  The  con- 
dition March  1,  1903,  is  shown  in  figure  163;  the  approximate 
outline  of  the  tumor  is  shown  with  fair  accuracy  by  the  white 
line  above  the  sternum. 

Case  137. — Man,  aged  sixty,  referred  to  me  by  Dr.  F.  E. 
Stevens,  of  Bristol,  Wis.  March,  1902,  he  had  a  group  of  glands 
removed  from  the  left  side  of  the  neck,  which  upon  microscopic 
examination  proved  to  be  round-celled  sarcoma.  These  had 
appeared  about  a  year  before  the  operation  and  gradually 
increased  in  size.  Soon  after  the  operation  there  reappeared 
under  the  scar  swelling  which  increased  slowly.  At  the  time 
he  was  referred  to  me,  August  6,  there  was  a  tumor  at  the 
junction  of  the  upper  and  middle  thirds  of  the  sternocleido- 
mastoid  muscle  the  size  of  a  large  olive.  It  was  hard,  tabulated, 
painless,  and  freely  movable.  Above  this  there  were  three 
hazelnut-sized  nodules  attached  to  the  skin  in  the  line  of  the 
scar.  From  August  6  to  date  the  patient  has  had  fifty-five 
exposures,  with  the  production  of  a  dry  dermatitis  twice. 
Under  these  exposures  the  masses  rapidly  shrank,  until  during 
the  last  month  they  are  just  palpable  and  are  almost  as  soft 
as  normal  tissue. 

Case  138. — Man,  aged  forty-one.  A  year  ago  a  nodule  de- 
veloped in  the  lower  lip  which  was  removed  by  a  V-shaped 
incision  and  which  proved  to  be  giant-celled  sarcoma. 
There  was  rapid  recurrence  in  the  scar,  and  when  he  came 
to  me  the  entire  lower  lip  was  involved  in  a  disc-shaped, 
densely  hard  infiltration,  with  an  ulcer  perforating  the  lip  at 
the  center.  He  had  had  x-ray  exposures  for  two  months  pre- 
viously without  effect.  At  my  hands  he  was  given  the  most 
vigorous  exposures  between  July  1  and  September  18,  with 
the  production  of  a  very  acute  weeping  dermatitis,  but  there 
was  no  effect  either  on  the  pain  or  on  the  size  of  the  tumor. 
Without  exception  I  have  never  seen  any  tumor  other  than 
osteosarcoma  so  hard,  and  the  denseness  of  the  infiltration 

34 


530  SARCOMA    AND    OTHER    GRAXULOMATA. 

may  perhaps  account  for  the  failure  to  relieve  pain.  By  Sep- 
tember 18  he  had  a  severe  x-ray  burn,  which  was  accompanied 
by  a  marked  softening  of  the  mass.  December  15 :  Without  fur- 
ther treatment  the  tumor  is  reduced  to  one-half  its  first  size, 
the  pain  has  disappeared,  the  patient  no  longer  needs  morphin, 
and  his  general  condition  is  much  improved. 

An  analysis  of  these  eleven  cases  is  not  discouraging.  In 
Cases  129,  130,  131,  and  134  there  was  general  sarcomatosis 
when  treatment  was  begun,  and  that  more  than  palliative 
results  would  be  obtained  was  not  expected.  One,  Case  138, 
is  perhaps  a  complete  failure.  Case  135  is  also  a  failure 
except  for  the  relief  of  pain,  but  that  was  a  case  of  osteo- 
sarcoma  so  extensive  that  anything  more  than  palliation  is 
hardly  conceivable.  In  the  other  cases  the  results,  while  by 
no  means  conclusive,  are  yet  of  a  most  striking  character. 
Cases  132,  136,  and  137  are  symptomatic  cures.  The  pa- 
tients have  been  relieved  of  pain,  have  been  restored  to 
health,  and-  the  tumors  have  disappeared.  If  these  cases  had 
been  operable,  and  they  were  not,  no  better  results  could  have 
been  obtained.  Case  128  has  proved  an  ultimate  failure,  but 
the  failure  is  not  altogether  to  the  discredit  of  the  method. 
Opportunity  was  not  offered  for  giving  adequate  treatment.  If 
there  had  been  sufficient  treatment  at  the  start,  and  a  repetition 
of  exposures  at  frequent  intervals  over  the  area  of  the  disease, 
it  seems  possible,  so  remarkable  was  the  course  of  the  case, 
that  a  better  showing  might  have  been  made.  These  cases  all 
illustrate  the  importance  of  having  patients  as  early  as  possible 
for  treatment.  It  cannot  be  expected  that  more  than  palliation 
can  be  attained  unless  the  cases  are  gotten  for  treatment  before 
general  sarcomatosis  has  developed. 

Sarcoma  of  the  Eye. — Harper  *  has  reported  a  case  of  melano- 
sarcoma  of  the  sclera,  which  was  treated  after  operation  to 
prevent  recurrence.  There  remained  after  the  operation  three 
dark  spots  of  pigmentation,  which  disappeared  under  x-ray 
exposures.  Nine  and  a  half  months  after  the  operation  there 
was  no  evidence  of  recurrence. 

I  have  treated  one  case  of  glioma,  recurring  after  operation 
for  glioma  of  the  retina. 

*  American  X-ray  Journal.  190:2.  iv,  p.  1164. 


MYCOSIS   FUNGOIDES.  531 

Case  139. — Negro  child,  aged  four  years,  referred  to  me  by 
Prof.  Casey  Wood,  of  the  University  of  Illinois.  In  this  case 
there  was  a  large  tumor  mass  filling  the  orbit  when  the  treatment 
was  begun.  The  exposures  were  pushed,  with  little  expectation 
of  a  cure,  in  order  to  prevent  the  development  of  the  large 
protruding  tumor  of  the  eye  that  was  to  be  expected  in  the 
case.  The  exposures  prevented  the  development  of  the  tumor 
on  the  surface,  and  in  Dr.  Wood's  opinion  the  case  pursued 
a  much  slower  course  than  would  ordinarily  be  expected.  The 
child  ultimately  died,  but  without  the  development  of  any 
external  tumor. 

Mycosis  Fungoides. — Walker  *  states  that  Jamieson  has 
treated  with  x-rays  a  case  of  mycosis  fungoides  with  very 
marked  improvement.  Scholtz  |  reports  that  in  two  cases  of 
mycosis  fungoides  premycotic  areas  and  small  tumors  disap- 
peared entirely  under  exposures  sufficient  to  cause  superficial 
necrosis. 

Case  140. — I  have  treated  with  x-rays  for  a  short  time  one 
case  of  mycosis  fungoides.  A  large  tumor  mass  on  the  back 
of  the  head,  and  two  patches  of  induration  which  were  just 
beginning  to  show  the  formation  of  tumors,  were  exposed 
every  other  day  for  one  month  with  very  great  improvement. 
There  were  innumerable  lesions,  however,  over  the  body,  and 
we  were  not  making  progress  sufficiently  fast  to  please  the 
patient,  so  he  declined  further  treatment.  There  would  seem 
to  be  good  reason  to  expect  great  benefit  from  the  use  of  x-rays 
in  mycosis  fungoides.  The  condition  usually  remains  without 
deep  metastases,  and  from  the  results  in  the  few  cases  that 
have  been  treated  it  seems  likely  that  these  tumors  could  be 
controlled  by  x-ray  exposures.  The  extent  of  the  lesions  would 
make  the  treatment  tedious,  but  there  seems  reason  to  hope 
that  the  course  of  this  disease  may  be  markedly  benefited  by 
the  persistent  use  of  x-rays. 

Granuloma  of  Uncertain  Character. — Case  141. — Man,  aged 
fifty-seven,  referred  to  me  by  Dr.  A.  J.  Ochsner.  Patient  came 
to  Augustana  Hospital,  in  Dr.  Ochsner 's  service,  October  20, 1901, 

*Brit.  Med.  Jonr.,  1902,  ii,  p.  1319. 

t  Arch.  f.  Derm.  u.  Syph.,  1902,  lix,  p.  421. 


532  SARCOMA   AND   OTHER   GRANULOMATA. 

when  the  following  history  was  taken:  "Two  months  ago  a  car- 
buncle developed  on  the  right  cheek.  The  whole  right  side  of 
face  became  painful  and  swollen;  this  swelling  subsided,  and 
three  weeks  ago  the  patient  noticed  a  small  soft  swelling  at 
site  of  carbuncle.  This  has  increased  to  present  size.  Has 
been  opened  three  times,  discharging  blood  and  serum.  No 
tenderness  or  pain.  Present  condition:  Right  cheek  slightly 
reddened  and  indurated.  Downward  and  forward  from  malar 
bone  a  soft  swelling  with  few  crusts,  2.5  cm.  in  vertical  diameter 
and  2  cm.  in  horizontal  diameter.  On  pressure,  discharges 
sero-purulent  fluid.  Mucous  membrane  on  inner  surface  oppo- 
site tumor,  smooth."  Dr.  Ochsner  removed  the  entire  mass, 
going  well  out  beyond  the  diseased  tissue,  and  closed  the  wound. 
The  wound  remained  clean,  but  failed  to  heal,  and  the  tissues 
around  began  to  break  down,  and  within  two  weeks  there  was 
an  unhealthy  ulcer  with  a  cavity  the  size  of  an  olive,  surrounded 
by  bluish,  flabby  tissue.  The  pathological  findings  were  not 
definite.  It  was  a  granuloma  with  numerous  giant  cells,  but 
its  character  was  not  definitely  determined.  The  case  was  then, 
November  2,  1901,  put  under  daily  x-ray  exposures,  and  practi- 
cally no  attention  paid  to  the  local  dressing.  In  two  weeks 
some  dermatitis  was  produced,  and  the  ulcer  began  rapidly 
to  fill  up.  In  three  weeks  it  was  healed  with  a  perfectly 
healthy  scar,  and  has  remained  well.  The  diagnosis  in  this 
case  was  not  positive,  but  in  Dr.  Ochsner 's  opinion  there  was 
strong  probability  of  its  being  sarcoma,  and  it  gave  every 
prospect  of  being  a  lesion  which  would  be  difficult  of  handling 
by  the  usual  surgical  procedures. 

Case  142. — Granuloma  of  uncertain  character,  probably  blas- 

tomycosis.     Mrs.       ,   aged    forty-three.     Six    years    ago 

patient  received  a  blow  below  the  left  knee,  followed  by  hema- 
toma  which  was  six  months  in  disappearing.  This  was  followed 
by  a  lump  under  the  skin  about  2  cm.  in  length,  which  slowly 
enlarged,  grew  dark  red,  and  finally  ulcerated.  In  1899  the 
ulcer  with  the  surrounding  tissue  was  removed.  The  wound 
healed,  but  after  several  months  ulceration  again  occurred,  and 
the  condition  has  persisted  during  the  subsequent  two  and  a 
half  years.  The  family  and  personal  history  were  negative. 


Fig.  164. — Blastomycosis  (?)  of  the  knee. 


REPORT  OF    CASES.  535 

Patient  has  had  no  miscarriage.  All  the  children  were  healthy 
in  infancy,  the  only  one  to  die  dying  of  cholera  morbus.  She 
has  had  no  skin  eruptions,  no  loss  of  hair,  no  sore  throat.  The 
physical  condition  is  negative — a  tall,  sparely  built  woman,  some- 
what anemic  and  nervous.  The  condition  at  the  time  she  came 
under  my  care  is  shown  in  figure  164.  There  was  a  large,  soft, 
purplish  tumor  involving  the  knee  on  the  front  and  outside. 
The  apex  of  this  mass  was  occupied  by  a  superficial,  indolent, 
horseshoe-shaped  ulcer,  surrounded  by  raised,  puffed  edges.  A 
superficial  slough  covered  nearly  the  whole  surface.  The  entire 
mass  was  movable,  extraordinarily  soft  and  flabby,  of  a  dark 
purplish  color,  and  markedly  pigmented.  Around  the  periphery 
of  the  tumor  the  surface  was  roughened  by  a  verrucose,  papillary 
thickening  of  the  skin.  The  patient  had  been  unable  to  use 
the  leg,  and  had  been  on  crutches  over  a  year.  The  case  had 
proved  totally  unamenable  to  treatment  and  amputation  of  the 
leg  had  been  advised. 

The  diagnosis  lay  between  syphilitic  gumma,  tuberculosis, 
sarcoma,  and  blastomycosis.  The  first  three  were  almost 
entirely  excluded  by  the  history  of  the  case  and  its  course 
and  the  appearance  of  the  lesion.  It  resembled  no  other  lesion 
that  I  had  ever  seen.  The  probability  of  its  being  blastomycetic 
dermatitis  did  not  occur  to  me  until  after  it  had  been  under 
treatment  for  two  weeks,  during  which  time  there  had  been 
marked  improvement  under  x-rays  and  1  : 10,000  bichlorid  wet 
dressings.  I  never  succeeded,  therefore,  in  making  cultures  of 
the  organisms.  As  soon  as  the  nature  of  the  condition  was 
suspected  a  piece  of  tissue  was  taken  for  examination  and 
attempts  at  cultures  made,  which  were  unsuccessful,  perhaps 
because  of  the  treatment.  The  salient  points  in  the  histological 
examination  of  the  tissue,  made  by  Mr.  Ruediger,  are  as  follows : 
"The  rete  appears  to  be  in  marked  hyperplasia,  producing 
branching  down-growths  which  form  an  irregular  network 
within  the  corium.  Leucocytes  in  various  numbers  are  scattered 
throughout  the  branching  epithelium  and  frequently  appear  in 
small  collections  forming  intercellular  abscesses.  Besides  poly- 
morphonuclear  leucocytes,  plasma  cells,  red  blood-corpuscles, 
detached  epithelium,  and  debris  of  various  kinds  are  seen 


536  SARCOMA    AND    OTHER    GRANULOMATA. 

within  the  abscesses.  The  corium  contains  a  large  number  of 
polymorphonuclear  leucocytes,  plasma  cells,  and  red  blood- 
corpuscles,  the  leucocytes  frequently  forming  dense  abscess-like 
collections  similar  to  the  abscesses  within  the  epithelium.  The 
characteristic  branching  hyperplasia  of  the  rete,  together  with 
the  mtra-epithelial  abscesses,  indicate  strongly  in  my  opinion 
blastomycetic  dermatitis." 

X-ra,y  exposures  were  begun  on  the  leg  on  March  3,  1902, 
and  between  March  3  and  June  2  she  received  eighteen  x-ray 
exposures,  at  an  average  distance  of  7  cm.  and  of  an  average 
duration  of  fifteen  minutes,  with  a  fairly  strong  light.  Two 
weeks  after  beginning  treatment,  when  blastomycosis  was  sus- 
pected, she  was  given  ten  grains  of  potassium  iodide  three 
times  daily.  During  the  two  weeks  preceding  the  administra- 
tion of  the  iodide  there  had  been  very  decided  shrinkage  of 
the  tumor  and  decrease  in  size  of  the  ulcer.  From  the  start 
the  improvement  wras  continuous,  and  by  June  2,  the  tumor 
had  entirely  disappeared  and  the  ulcer  was  replaced  by  healthy 
scar  tissue  (Fig.  165).  The  function  of  the  knee  was  not  dam- 
aged, and  she  was  using  the  leg  without  crutches,  as  she  has 
continued  to  do  since  that  time.  The  case  had  seven  exposures 
between  June  2  and  July  2,  as  a  prophylactic  measure.  Since 
that  time  there  have  been  no  exposures  and  the  leg  remains 
perfectly  well.  At  no  time  during  the  treatment  was  there 
produced  more  than  the  slightest  evidence  of  x-ray  reaction. 
The  subsidence  of  the  mass  was  most  remarkable,  particularly 
when  one  takes  into  consideration  its  course  and  its  apparently 
malignant  character.  During  the  entire  time  of  treatment  the 
leg  was  dressed  daily  with  1  : 10,000  bichloride  dressing.  During 
most  of  the  time  that  she  was  under  treatment  the  patient 
had  ten  grains  of  iodide  of  potassium  three  times  daily,  and 
that,  of  course,  militates  somewhat  against  the  conclusiveness 
of  the  demonstration  of  effect  of  x-rays  in  the  case.  The  patient 
had,  however,  previously  had  vigorous  treatment  with  potassium 
iodide  without  effect.  Moreover,  iodide  of  potassium,  to  be 
effective  in  blastomycetic  dermatitis,  has  to  be  given  in  large 
doses,  and  while  such  doses  of  potassium  iodide  have  a  marked 
favorable  effect  upon  blastomycetic  dermatitis,  the  use  of 


REPORT   OF   CASES.  537 

potassium  iodide  alone  has  not  been  found  sufficient  to  cure 
the  cases  entirely.  Vigorous  local  treatment  of  the  lesions  has 
to  be  called  to  its  aid.  There  can  be,  therefore,  little  doubt 
of  the  fact  that  the  result  in  this  case  was  almost  entirely  due 
to  the  effect  of  x-rays. 


CHAPTER  XV. 


THE  PROPHYLACTIC  USE  OF  X-RAYS  AFTER  OPER- 
ATIONS FOR  MALIGNANT  DISEASES. 

THE  use  of  x-ray  exposures  after  operations  for  malignant 
tumors  as  a  method  of  prophylaxis  is  unquestionably  a  logical 
procedure,  and  it  is  being  carried  out  at  the  present  time  by 
many  workers.  The  time,  however,  is  too  short  for  any  data 
upon  the  subject  to  be  valuable.  The  method  was  first  under- 
taken by  me  in  June,  1901,  at  the  suggestion  of  Prof.  T.  A. 
Davis,  of  the  University  of  Illinois,  on  a  patient  of  his,  and 
I  have  been  using  x-rays  in  this  way  since  that  time.  I  have 
records  of  twenty-one  cases  of  carcinoma  or  sarcoma  in  which 
the  procedure  has  been  carried  out,  and  in  which  considerable 
time  has  elapsed  since  operation.  The  cases  are  as  follows : 

14  cases  after  operation  for  carcinoma  of  the   breast 


1  case 

1 

1 

1 

1 

1 

1 


jaw. 

uterus. 

rectum. 

lip. 

muscles  of  the  shoulder. 

finger. 

iris. 


Of  course,  the  list  is  not  large  enough,  and  the  time  that  has 
elapsed  is  not  long  enough,  to  allow  of  any  deductions  as  to 
the  value  of  the  method.  The  course  of  some  of  the  cases, 
however,  is  such  as  to  give  good  reason  to  believe  that  the 
use  of  x-rays  has  had  a  positive  influence  in  preventing  the 
recurrence  of  the  disease.  Such  cases  are  as  follows : 

Cose  143. — Mrs.  ,  aged  forty-five,  referred  to  me  by 

Dr.  T.  A.  Davis,  of  Chicago,  after  radical  operation  for  removal 
of  the  breast.  The  operation  had  been  done  eight  weeks  pre- 
viously. At  the  time  of  beginning  treatment  there  was  a 
healthy  scar,  but  the  arm  was  oedematous,  and  she  had  a  good 

538 


REPORT   OF    CASES.  539 

deal  of  pain.  In  Dr.  Da  vis's  opinion  the  danger  of  recurrence 
within  a  few  months  was  very  great.  The  case  has  had  several 
series  of  x-ray  exposures  between  June,  1901,  and  the  present 
time,  the  reaction  being  carried  each  time  to  the  point  of 
producing  a  moderate  dry  dermatitis.  Soon  after  beginning 
treatment  the  swelling  in  the  arm  and  the  pain  began  to  dimin- 
ish. This  continued  until  she  was  practically  free  from  pain, 
and  the  arm  had  gotten  free  from  oedema.  Four  months  after 
beginning  treatment  the  arm  swelled  again,  and  Dr.  Davis  and 
I  both  expected  that  the  recurrence  was  at  hand.  Under  x-ray 
exposures,  however,  the  swelling  disappeared,  and  the  patient 
remains  well  at  the  present  time,  sixteen  months  after  the 
operation. 

Case  144. — Man,  aged  sixty,  referred  to  me  by  Dr.  A.  J. 
Ochsner.  In  March,  1898,  Dr.  Fenger  removed  the  right  side 
of  the  lower  jaw,  and  in  three  subsequent  operations,  October, 
1899,  May,  1900,  and  January,  1901,  he  removed  recurrent 
masses  of  carcinoma  in  that  side  of  the  face  and  neck.  This 
patient  was  referred  to  me  by  Dr.  Ochsner  July  1,  1902,  with 
a  view  to  overcoming  a  possible  recurrence.  There  were  no 
masses  palpable,  but  he  was  beginning  to  have  some  pain  in 
the  region  of  the  operation  and  other  subjective  sensations  such 
as  had  preceded  the  former  recurrences.  He  has  had  x-ray 
exposures  between  July,  1902,  and  the  present  time  to  the 
point  of  causing  thinning  of  the  beard  and  producing  a  slight 
dermatitis  on  several  occasions.  As  a  result,  his  pain  promptly 
ceased  and  has  not  returned.  In  October,  1902,  he  was  exam- 
ined again  by  Dr.  Ochsner,  and  in  Dr.  Ochsner 's  opinion  was 
well.  It  is  now  fourteen  and  a  half  months  since  the  last 
operation  and  the  longest  previous  respite  was  nine  months. 

Case  145. — Mrs. ,  aged  thirty-seven,  referred  to  me  by 

Dr.  A.  J.  Ochsner.  October  12, 1901,  Dr.  Ochsner  did  a  hysterec- 
tomy for  carcinoma  uteri,  removing  at  the  same  time  part  of 
the  bladder-wall  which  was  involved.  There  was  great  fear  in 
this  case  of  recurrence.  This  patient  had  four  series  of  x-ray 
exposures  between  November  30,  1901,  and  August  30,  1902, 
and  the  exposures  are  to  be  given  again  in  January,  1903. 
There  has  been  no  evidence  of  recurrence  of  the  disease.  The 


540  PROPHYLACTIC  USE  OF   X-RAYS. 

patient  has  gained  flesh,  has  been  entirely  free  from  pain  and 
is  in  her  normal  robust  health,  a  year  after  operation. 

Case  146. — Mrs. ,  aged  forty,  referred  to  me  by  Dr. 

A.  J.  Ochsner,  of  Chicago,  and  Dr.  W.  J.  Mayo,  of  Rochester, 
Minn.  Four  weeks  previously  a  growth  had  developed  after  a 
bruise  on  the  inner  side  of  the  left  thumb.  This  was  recognized 
as  a  sarcoma,  and  immediately  excised.  Microscopic  diagnosis 
showed  it  to  be  round-celled  sarcoma.  Nothing  was  done  except 
the  excision  of  the  growth,  as  the  patient  refused  a  more  radical 
operation.  When  she  was  referred  to  me,  March  3,  1902,  there 
was  every  reason  to  believe  that  metastases  would  develop 
almost  immediately  in  other  parts  of  the  body.  Dr.  Ochsner 
stated  to  me  that  if  she  did  not  show  sarcoma  elsewhere  within 
a  few  months  there  could  be,  in  his  opinion,  no  doubt  as  to 
the  positive  effect  of  the  x-rays.  The  most  intense  exposures 
were  begun  and  given  daily  over  the  thumb.  There  was  hardly 
an  appreciable  dermatitis,  but  under  x-rays  the  tissues  of  the 
thumb  shriveled  up  until  they  looked  almost  mummified.  Ex- 
posures were  also  given  over  the  entire  length  of  the  arm,  the 
axilla,  and  the  mediastinal  glands.  She  was  under  treatment 
for  only  a  month  and  a  half.  Up  to  the  present  time,  after 
nine  months,  there  has  been  no  recurrence. 

It  is  interesting  to  contrast  with  this  an  identically  similar 
clinical  picture,  in  a  patient  with  a  sarcoma  on  the  inner  side 
of  the  middle  finger,  who  was  referred  to  me  by  Dr.  H.  X. 
Mover,  of  Chicago,  on  July  1,  1901.  The  case  was  recognized 
as  a  sarcoma,  and  I  advised  a  radical  operation,  to  be  followed 
by  x-ray  exposures.  The  patient  did  not  have  this,  but  within 
three  weeks  after  the  first  evidence  of  the  tumor  he  had  the 
mass  excised,  and  there  was  prompt  healing.  He  sent  me  the 
tissue  and  it  proved  to  be  round-celled  sarcoma.  He  did  not 
have  an}7  x-ray  exposures  and  within  three  months  other  tumors 
developed.  On  June  1,  1902,  eleven  months  after  the  opera- 
tion, he  was  in  the  last  stage  of  general  sarcomatosis. 

Case  147. — Mrs.  ,  aged  forty-five,  referred  to  me  by 

Dr.  E.  J.  Mellish,  of  El  Paso,  Texas,  on  November  1,  1901. 
She  had  just  recovered  from  an  extensive  operation  for  small 
round-celled  sarcoma,  beginning  on  the  upper  and  back  part 


THE    USE    OF    X-RAYS    PRELIMINARY   TO    OPERATION.         541 

of  the  right  shoulder,  and  Dr.  Hellish  was  very  fearful  of  re- 
currence in  the  case.  This  patient  has  had  several  series  of 
exposures  during  the  last  year,  and  there  is  at  present,  fifteen 
months  after  the  operation,  no  evidence  of  recurrence. 

In  one  case  treated  after  operation  for  carcinoma  of  the 
breast  there  has  been  a  recurrence  in  a  gland  under  the  pectoral 
muscle  and  in  a  supraclavicular  gland.  The  pectoral  gland  was 
removed  and  under  x-ray  exposures  the  supraclavicular  gland, 
which  appeared  six  weeks  ago,  has  now  disappeared. 

The  cases  narrated  above  in  which  there  has  been  no  re- 
currence of  course  prove  nothing,  because  they  are  too  few, 
the  time  is  too  short,  and  we  do  not  know  that  there  would 
have  been  recurrences  if  there  had  been  no  prophylactic  expo- 
sures. Nevertheless,  these  were  patients  with  the  most  gloomy 
outlook,  and  their  surgeons  had  the  greatest  fears  of  early  re- 
currence ;  and  the  fact  that  the  recurrences  have  not  developed 
after  a  year  or  more  is  of  some  significance. 

The  Use  of  X-rays  Preliminary  to  Operation. — X-rays  will  also 
doubtless  have  a  field  of  usefulness  in  the  treatment  of  cases 
of  malignant  disease,  preliminary  to  operation,  where  for  any 
reason  it  is  not  advisable  or  is  impossible  to  have  the  operation 
without  some  delay.  The  situation  where  this  use  of  the  x-rays 
suggests  itself  most  naturally  is  in  cases  which  must  be  built 
up  before  operation.  In  such  cases  it  would  doubtless  be 
possible  at  times  to  inhibit  the  development  of  the  growth 
and  thus  render  less  dangerous  the  delay  before  operation.  My 
Case  128  of  sarcoma  was  a  case  in  which  x-rays  were  first  used 
for  this  purpose. 


CHAPTER  XVI. 

PSEUDO-LEUKEMIA,  LEUKEMIA,  AND  VARIOUS 
OTHER  AFFECTIONS. 

Hodgkin's  Disease. — Hett  *  has  reported  a  case  of  pseudo- 
leukemia  of  three  years'  standing,  in  a  child  aged  twelve.  The 
left  cervical  glands  were  very  much  enlarged,  the  spleen  was 
enlarged,  and  there  was  marked  cachexia.  A'-rays  were  applied 
for  three  weeks  with  disappearance  of  the  enlarged  glands.  In 
a  personal  communication  to  me  he  states  that  there  has  been 
recurrence,  but  part  of  the  improvement  has  been  maintained. 

Williams  f  has  reported  one  case  of  pseudo-leukemia  treated 
with  x-rays,  a  young  man  who  developed  Hodgkin's  disease 
with  enlarged  axillary  and  cervical  glands  and  an  enormously 
enlarged  spleen.  At  the  time  of  his  report  the  spleen  was 
much  smaller  and  all  of  the  glands  had  become  softer,  and 
most  of  them  could  not  be  seen  or  felt. 

The  first  case  of  Hodgkin's  disease  treated  by  this  method 
was  the  following  case  of  mine: 

Case  148. — Child,  aged  four  years,  referred  to  me  by  Dr. 
A.  J.  Ochsner.  The  diagnosis  of  Hodgkin's  disease  had  been 
made  by  Dr.  Ochsner  and  Dr.  Christian  Fenger,  as  well  as  by 
others.  The  disease  began  in  December,  1900,  as  a  small  hard 
swelling  below  the  ears.  The  mother  stated  that  every  two 
or  three  days  she  could  see  more  of  the  swellings  appear.  In 
May,  1901,  the  patient  was  in  the  Presbyterian  Hospital  under 
the  care  of  Dr.  Fenger,  to  whose  aid  I  am  indebted  for  most 
of  the  history.  When  the  patient  entered  the  Presbyterian 
Hospital  the  following  notes  were  made:  " Submaxillary,  cervi- 
cal, and  supraclavicular  lymph-glands  are  enlarged,  hard,  dis- 
crete. There  are  tense  swellings,  both  anteriorly  and  poste- 
riorly, especially  on  the  left  side  of  the  neck.  No  other  enlarged 

*  Dominion  Med.  Monthly,  1902,  xix,  p.  76. 
f  "  Rontgen  Rays  in  Medicine  and  Surgery,"  p.  675. 
542 


I! 


\ 


p6w 


543 


HODGKIN'S  DISEASE.  545 

lymph-glands  are  found."  The  blood  count  showed  4,300,000 
reds  and  10,000  whites.  Hemoglobin  50  per  cent. 

Dr.  Fenger  dissected  out  two  lymph-glands  in  the  neck,  and 
"the  pathologist 's  report  states  that  there  is  no  evidence  of 
tuberculosis  in  the  gland  and  that  the  histology  coincides  with 
that  of  a  pseudo-leukemia. "  The  diagnosis  of  Hodgkin's  disease 
was  made  and  the  patient  discharged  with  a  "statement  to 
parent  that  little  if  anything  can  be  done  to  relieve  patient." 
In  August,  1901,  patient  entered  Augustana  Hospital  in  Dr. 
Ochsner's  service.  The  condition  of  the  swellings  at  that  time 
is  indicated  in  the  following  note:  "A  large,  irregular  swelling 
on  the  right  side  of  the  neck,  size  of  a  small  fist,  extending 
from  below  and  behind  the  right  ear  to  the  clavicle.  Numerous 
hard  masses,  varying  in  size  from  a  filbert  to  an  English  walnut, 
can  be  felt.  Small  swellings  of  the  left  side  of  the  neck  about 
half  the  size  of  that  on  the  right.  The  swellings  are  not  tender, 
painful,  or  red,  and  are  freely  movable.  No  enlargement  of 
liver  or  spleen."  The  diagnosis  of  Hodgkin's  disease  was  made 
and  Dr.  Ochsner  dissected  out  a  large  mass  of  glands  on  the 
right  side  of  the  neck. 

On  September  11  he  referred  the  case  to  me  for  exposures 
to  x-rays.  The  condition  then  is  shown  in  figure  166.  There 
was  a  healthy  scar  on  the  right  side  of  the  neck  and  on  the 
left  side  a  swelling  the  size  of  a  small  fist,  made  up  of  a  group 
of  greatly  enlarged  glands.  They  were  hard,  painless,  and  freely 
movable.  These  glands  were  put  under  exposures  to  the  rays 
on  September  11.  In  the  course  of  a  month  erythema  was 
produced  and  the  glands  rapidly  diminished  in  size.  At  the  end 
of  two  months  there  remained  three  or  four  small  glands  on 
this  side  of  the  neck  which  were  quite  soft  and  not  larger  than 
a  filbert.  Almost  all  the  swelling  had  disappeared  and  the 
slight  swelling  that  remained  was  as  soft  as  adipose  tissue. 
The  condition  at  that  time  is  shown  in  the  accompanying  illus- 
tration (Fig.  167). 

There  had  been  correspondingly  great  improvement  hi  the 
general  physical  and  mental  condition  of  the  patient.  He  had 
been  changed  from  a  cachectic,  sluggish  child,  to  a  bright  lively 
one.  The  number  of  red  and  white  blood-corpuscles  had  re- 

35 


546  PSEUDO-LEUKEMIA    AND    OTHER    AFFECTIONS. 

mained  about  the  same,  but  there  had  been  an  increase  in 
the  hemoglobin  to  80  per  cent,  as  compared  with  50  per  cent, 
at  the  beginning  of  treatment.  After  the  middle  of  November 
he  had  very  desultory  treatment.  On  January  28,  1902,  after 
he  had  been  given  a  few  prophylactic  treatments,  the  following 
notes  were  made:  "Glands  in  the  neck  not  bigger  than  peas. 
One  or  two  inguinal  and  axillary  glands  about  the  size  of  a 
filbert.  Epitrochlears  not  palpable."  On  April  22,  after  the 
treatment  had  been  neglected  for  three  months,  he  returned 
with  the  glands  on  the  left  side  of  the  neck  hard  and  about 
half  as  large  as  they  were  when  I  first  saw  him.  Between 
April  22  and  June  10  he  had  fifteen  exposures  over  the  cervical 
glands,  with  disappearance  of  the  swelling.  On  June  2  the 
following  note  was  made:  "Masses  on  left  side  of  neck  entirely 
softened,  except  a  portion  the  size  of  a  large  pea,  which  remains 
hard.  Right  side  of  neck  free  from  any  swelling  or  palpable 
glands."  The  blood  examination  at  that  time  showed: 

R.  B.  C 4,096,000 

W.  B.  C 5000 

Hemoglobin ...  53  per  cent. 

After  that  time  he  received  ten  exposures  between  June  13 
and  July  28.  Then  his  parents  discontinued  the  treatment  and 
I  did  not  see  him  again.  There  was  a  recurrence  of  the  glands 
in  the  neck,  for  which  an  operation  was  done  the  last  of  Octo- 
ber, and  a  few  days  later  he  died  of  inspiration  pneumonia. 

Case  149. — Man,  aged  fifty,  referred  to  me  by  Dr.  L.  L.  Mc- 
Arthur.  The  patient  had  typhoid  fever  five  years  before,  but 
aside  from  that  had  no  serious  illness  since  childhood.  In 
childhood  he  had  an  attack  of  inflammatory  rheumatism, 
otherwise  his  personal  and  family  history  are  negative. 

In  April,  1900,  he  noticed  a  swelling  under  the  right  arm 
and  another  on  the  inside  of  the  elbow.  These  gradually  in- 
creased in  size,  and  in  October,  1900,  he  consulted  Dr.  D.  N. 
Eisendrath,  who  found,  in  addition,  enlarged  glands  in  the 
neck,  in  the  other  axilla,  in  the  groins,  and  along  the  side  of 
the  abdomen.  The  case  was  seen  in  consultation  by  Dr.  Chris- 
tian Fenger,  who  agreed  with  Dr.  Eisendrath  in  the  diagnosis 


547 


HODGKIN'S  DISEASE.  549 

of  Hodgkin's  disease.  The  diagnosis  of  Hodgkin's  disease  was 
also  made  by  Dr.  E.  J.  Dohring  and  Dr.  M.  L.  Goodkind.  The 
blood  examination  made  at  the  time  that  Dr.  Eisendrath  saw 
the  case  showed  80  per  cent,  hemoglobin,  5,000,000  red  corpus- 
cles, and  10,000  whites. 

Previous  to  beginning  treatment  with  x-rays  the  patient  had 
for  a  long  time  been  taking  arsenic,  and  for  several  weeks 
had  been  having  parenchymatous  injections  of  arsenic  into  the 
tumors.  In  spite  of  this  treatment  the  glands  had  not  de- 
creased. The  patient's  general  health  had  failed  and  he  showed 
marked  cachexia. 

The  size  of  the  tumor  in  the  right  axilla -when  x-ray  treatment 
began  is  shown  in  figure  168.  It  was  about  as  large  as  a  child's 
head  and  interfered  seriously  with  the  movement  of  the  arm. 
The  right  epitrochlear  gland  was  almost  as  large  as  a  goose-egg. 
Its  vertical  diameter  was  four  inches  and  its  transverse  diameter 
was  about  two  and  one-half  inches.  Both  of  the  glands  were 
movable  but  densely  hard. 

At  Dr.  Me  Arthur's  suggestion  I  began  daily  exposures  over 
the  right  epitrochlear  gland  November  19,  1901,  while  he  con- 
tinued the  parenchymatous  injections  of  arsenic  in  the  axillary 
gland.  By  December  18  I  had  produced  considerable  erythema 
over  the  elbow  and  the  gland  was  reduced  to  less  than  half 
its  previous  size.  In  the  mean  time  the  axillary  gland,  which 
was  having  injections  of  arsenic,  showed  no  change.  These 
injections  were  then  stopped,  and  at  Dr.  McArthur's  suggestion 
I  began  exposures  also  over  the  axillary  glands.  The  expo- 
sures over  the  epitrochlear  gland  were  continued,  and  by 
January  1,  1902,  all  apparent  swelling  had  disappeared  and 
only  a  soft  gland  the  size  of  a  filbert  was  left.  By  January 
7,  after  fifteen  sittings,  and  upon  the  development  of  consider- 
able erythema,  the  axillary  gland  had  become  quite  soft  and 
very  much  reduced  in  size.  By  January  20,  all  of  the  axillary 
swelling  had  disappeared.  The  condition  of  the  axilla  at  that 
time  and  as  it  has  remained  for  a  year  is  shown  in  figure  169. 
There  was  very  slight  puffiness  at  the  site  of  this  tumor,  but 
it  was  as  soft  as  the  softest  adipose  tissue.  The  man's  general 
physical  condition  has  been  greatly  improved.  Dr.  M.  L.  Good- 


550  PSEUDO-LEUKEMIA    AXD   OTHER  AFFECTIONS. 

kind,  who  saw  the  patient  after  an  interval  of  several  months, 
particularly  called  my  attention  to  the  improvement  in  his 
general  condition,  which  he  characterized  as  astounding. 

The  patient  was  discharged  January  20,  1902,  and  told  to 
report  occasionally;  to  report  immediately  if  any  enlarged 
glands  developed.  On  September  16,  eight  months  later,  he 
returned  with  enlarged  glands  in  the  left  groin,  the  left  axilla, 
and  the  left  side  of  the  neck,  the  largest  about  the  size  of  an 
English  walnut.  This  change  he  had  noticed  first  a  few  days 
before.  He  had  also  begun  to  run  down  somewhat  physically. 
Under  sixteen  exposures  between  September  16  and  October 
17  all  of  the  glands  -disappeared  without  the  development  at 
any  time  of  more  than  slight  erythema.  He  was  also  feeling 
very  much  better  physically  than  when  he  returned  for  treat- 
ment. He  remains  well. 

During  the  first  period  that  this  patient  had  x-ray  exposures 
he  also  had  the  free  use  of  arsenic,  and  it  was  a  question  as 
to  how  much  of  a  factor  the  arsenic  was  in  the  reduction  of 
the  glands.  During  the  last  period  of  treatment  he  was  given 
no  arsenic,  or  other  medicine,  so  that  all  factors  except  x-rays 
were  ruled  out.  The  result  in  this  case  is  a  very  positive  one. 
When  he  began  treatment  in  November,  1901,  he  had  been 
so  run  down  in  health  for  several  months  that  he  had  been 
unable  to  attend  to  business.  Since  the  first  of  January,  1902, 
he  has  felt  as  well  as  he  ever  did  and  has  vigorously  pursued 
an  exacting  occupation.  There  has  been  no  interruption  in 
his  work  in  the  entire  eleven  months. 

Case  150. — Child,  aged  six  years,  referred  to  me  in  the  last 
stages  of  cachexia  from  pseudo-leukemia.  There  were  large 
masses  in  various  parts  of  the  body.  He  had  thirteen  moderate 
exposures  without  the  production  of  an  erythema  and  without 
effect,  and  treatment  was  discontinued  by  the  patient.  There 
was  no  effect  upon  the  tumors,  but  not  enough  reaction  was 
produced  to  expect  any  effect,  and  the  case  is,  I  think,  of  no 
weight. 

I  have  treated  one  other  case  in  which  a  diagnosis  of  prob- 
able Hodgkin's  disease  was  made. 

Case  .151. — Miss  ,  aged  twenty-one.     In  March.  1902, 


HODGKIN'S  DISEASE.  551 

after  a  month  of  lassitude,  the  patient  went  to  bed  with  what 
was  thought  to  be  typhoid  fever.  In  May,  1902,  she  came  to 
Chicago,  and  a  diagnosis  of  probable  Hodgkin's  disease  was 
made  by  Prof.  Robert  H.  Babcock,  of  the  University  of  Illinois, 
and  by  others.  At  the  time  that  she  was  referred  to  me  there 
was  a  group  of  three  or  four  hard  glands  the  size  of  a  small 
olive  on  the  right  side  of  the  neck  above  the  inner  end  of  the 
clavicle.  There  was  a  gland  the  size  of  an  olive  under  the 
border  of  the  pectoral  muscle  in  the  left  axilla,  and  a  gland 
the  size  of  a  filbert  at  the  outer  side  of  the  elbow.  Blood 
examination  showed: 

K.  B.  C 3,208,000 

W.  B.  C 4200 

Hemoglobin 63  per  cent. 

Small  mononuclears 35  per  cent. 

Large  mononuclears 4  per  cent. 

Polymorphonuclears 58  per  cent. 

Eosinophiles  and  a  few  poikilocytes     .    . ' 3  per  cent. 

Many  small  mononuclears  showed  distinct  chromatin  network 
in  the  nucleus,  with  a  faintly  stained  non-granular  margin  about 
the  nucleus  in  a  few.  Nuclei  eccentrically  placed. 

During  the  previous  two  months  the  patient  had  a  very  low 
grade  of  fever,  but  in  the  last  two  weeks  had  improved  con- 
siderably. Between  July  2  and  July  21,  1902,  she  received 
nine  fairly  strong  exposures,  with  the  production  of  a  slight 
erythema.  By  July  21  all  of  the  glands  had  disappeared,  and 
the  patient  remains  well  at  the  present  time. 

It  must  of  course  be  remembered  that  the  tumors  in  pseudo- 
leukemia  disappear  spontaneously  at  times,  and  in  Case  151 
I  think  that  this  factor  of  spontaneous  disappearance  of  tumors 
cannot  be  excluded.  But  in  Cases  148  and  149  any  simple 
coincidence  between  the  disappearance  of  the  glands  and  the 
x-ray  exposures  can  be  clearly  ruled  out.  In  neither  of  these 
cases,  after  a  year  and  a  year  and  a  half  respectively,  had  any 
tendency  to  spontaneous  disappearance  of  the  glands  shown 
itself,  and  there  was  no  acute  disturbance  of  the  health  at  the 
time  that  these  cases  were  under  x-ray  treatment  to  precipitate 
the  subsidence  of  the  glands.  The  sequence  of  the  exposure 


552  PSEUDO-LEUKEMIA    AND    OTHER   AFFECTIONS. 

to  the  x-rays  and  the  subsidence  of  the  glands  was  as  close 
and  direct  as  possible.  In  each  instance  evidence  of  the  effect 
on  the  glands  began  to  show  itself  just  before  the  corresponding 
effect  upon  the  skin  was  produced,  and  this  phenomenon  was 
seen  in  a  sufficient  number  of  instances  to  mathematically  rule 
out  the  possibility  of  coincidence. 

Leukemia. — I  have  treated  two  cases  of  true  leukemia  with 
x-rays. 

Case  152. — Mrs.  ,  aged  fifty,  referred  to  me  by  Dr. 

A.  J.  Ochsner.  The  patient  had  a  spleen  filling  all  the  right 
side  of  the  abdomen,  but  without  other  glandular  involvement, 
and  the  blood  examination  showed: 

R.  B.  c 3,000,000 

W.  B.  C 300,000 

Hemoglobin 50  per  cent. 

She  was  given  x-ray  exposures  for  a  month  with  no  effect 
whatever.  The  exposures,  however,  were  not  carried  to  the 
point  of  producing  any  effect  on  the  skin,  and  in  my  judgment 
the  case  shows  nothing. 

Case  153. — Man,  aged  forty-four,  referred  to  me  by  Dr.  Jacob 
Frank,  of  Chicago.  The  family  and  personal  history  of  the 
patient  were  negative.  In  March,  1901,  the  present  illness 
began  with  a  chill,  followed  by  a  fever  lasting  two  days.  He 
felt  well  until  a  month  afterward,  when  he  had  an  exactly 
similar  attack.  On  June  15,  1901,  he  had  a  third  chill,  followed 
by  fever,  and  on  the  third  day  of  this  attack  a  large  swelling, 
hard  and  red,  appeared  on  the  left  side  of  the  neck,  causing 
constant  pain.  This  swelling  was  incised  on  June  20  without 
finding  pus.  A  week  later,  under  hot  dressings,  a  small  amount 
of  pus  was  discharged.  After  this  he  had  several  small  abscesses 
in  various  parts  of  the  neck.  Early  in  September,  1901,  a 
swelling  the  size  of  a  man's  fist  appeared  in  the  left  axilla, 
which  was  removed  surgically,  and  later  swellings  appeared 
again  in  the  left  axilla  and  in  both  groins.  Within  the  last 
month  the  tumors  in  the  right  cervical  and  axillary  regions 
had  decreased  in  size  somewhat.  For  about  two  months  the 
patient  had  been  hoarse.  His  condition  at  the  time  he  came 


s 


553 


LEUKEMIA.  555 

to  me  March  6,  1902,  is  shown  in  figure  170.  In  the  right  axilla 
there  was  a  mass  of  five  or  six  glands  varying  from  the  size 
of  a  walnut  to  larger  than  an  egg.  On  the  right  side  of  the 
neck  there  was  a  very  large  mass  of  glands,  ten  or  twelve  in 
number,  the  largest  the  size  of  a  small  egg.  All  were  freely 
movable,  fairly  hard,  and  painless.  The  circumference  of  the 
neck  just  under  the  chin  was  eighteen  inches.  In  either  groin 
there  were  masses  of  glands  the  size  of  a  walnut  and  smaller, 
not  freely  movable,  but  painless.  The  liver  was  palpable  in 
the  parasternal  line  10  cm.  below  the  costal  margin,  the  edge 
sharp,  firm,  and  not  tender.  Greatest  enlargement  in  left  lobe. 
The  spleen  was  distinctly  palpable  8  cm.  below  the  costal 
margin,  the  edge  hard,  round,  and  not  tender.  The  diagnosis 
of  leukemia  had  been  made  by  Dr.  Jacob  Frank,  Dr.  Frank 
Billings,  and  others.  He  was  cachectic  to  the  last  degree. 

Between  March  1  and  March  25,  1902,  he  received  eighteen 
fairly  vigorous  exposures  with  the  development  of  slight  dry. 
dermatitis,  and  the  marked  subsidence  of  the  exposed  glands. 
A  few  days  after  the  last  exposure  he  was  attacked  with  an 
acute  illness  which  resembled,  his  physician  stated,  a  miliary 
tuberculosis.  On  the  morning  of  the  first  day  of  his  illness 
he  found  that  the  glands  which  had  been  noticeable  the  night 
before  in  his  neck  had  disappeared.  When  he  returned  after 
his  illness  on  May  7,  1902,  the  glands  had  almost  completely 
disappeared,  as  shown  in  figure  171.  The  glands  on  the  left 
side  of  the  neck  had  entirely  disappeared.  In  the  right  axillary 
and  cervical  regions  one  gland  in  each  remained ;  these  were  of 
the  size  of  a  lima  bean  and  quite  soft.  The  inguinal  glands  were 
soft  and  small,  the  largest  the  size  of  a  hazelnut.  The  spleen 
was  softer  and  smaller,  reaching  6  cm.  below  the  costal  margin. 
The  liver  remained  as  large  as  on  previous  examination.  After 
this  his  general  physical  condition  improved  very  much.  He 
was  able  to  go  away  for  the  summer  and  take  a  long  journey 
without  overtaxing  himself.  In  the  middle  of  June  blood 
examination  showed  a  considerable  improvement.  September 
6  he  returned  with  a  new  group  of  enlarged  glands  on  the 
right  side  of  the  neck  and  in  the  right  axilla,  for  which  he 
received  four  strong  exposures,  that  were  followed  by  the 


556 


PSEUDO-LEUKEMIA   AND   OTHER    AFFECTIONS. 


disappearance  of  the  glands.  A  few  weeks  later,  however, 
they  began  to  increase  rapidly,  and  the  patient  died  in  the 
middle  of  November,  1902,  in  an  acute,  apparently  septic 
attack,  such  as  he  had  had  from  the  beginning  of  the  disease. 
There  seems  little  reason  to  doubt  the  direct  effect  of  x-ray 
exposures  upon  the  glands  in  this  case.  The  disappearance  of 
tumors  was  in  close  sequence  with  the  x-ray  exposures,  and 
they  had  never  disappeared  in  the  fifteen  preceding  months 
of  his  illness.  The  patient  was  not  willing  to  have  as  persistent 
treatment  as  Dr.  Frank  and  I  thought  he  should  have  and 
his  treatment  was  recognized  at  the  time  as  inadequate. 

The  blood-counts  in  this  case  at  different  times  were  as  follows : 


MAR.  6,  1902. 

APRIL  9,  1902. 

SEPT.  6,  1902. 

Red  blood-corpuscles 
White  corpuscles 
Hemoglobin   . 

2,768,000 
74,300 

45% 

2,160,000 
12,000 
43.0% 

2,480,000 
102,700 

48.0% 

Polymorpbonuclears 
Large  mononuclears 
Small  mononuclears 
Eosinophiles  

14# 

5% 
80% 
\% 

41.1% 

4.2% 
53.3% 
1.1% 

15.6% 

0.8% 
81.8% 
0.3% 

Mast  cells  
Nucleated  reds  

A  very  few 

0.3% 
1.0% 

1.3% 

Non-granular    polymorpho- 
nuclears  

0.2% 

The  use  of  x-rays  has  been  tried  also  in  a  few  cases  of  numer- 
ous other  affections.  In  some  of  these  there  have  been  logical 
indications  for  the  use  of  the  method;  in  others  it  has  been 
tried  empirically. 

Neuralgias. — Stembo  *  has  reported  28  cases  of  neuralgia, 
including  all  of  the  ordinary  forms  of  that  affection,  which  he 
has  treated  with  x-rays.  Of  these  21,  or  75  per  cent.,  were 
promptly  relieved.  He  found  that  relief  usually  followed  three 
exposures. 

Gocht  t  has  reported  the  case  of  a  man  seventy-six  years  old 
who  had  suffered  from  trigeminal  neuralgia  of  the  right  side 
for  ten  years,  large  doses  of  morphin  being  required  to  control 


*  Therapie  der  Gegenwart,  1900,  N.  F.  ii,  p.  250. 

f  Fortschritte  a.  d.  Geb.  d.  Rontgenstrablen,  1897,  i,  p.  14. 


RHEUMATISM — PRURITUS.  557 

the  pain.  He  applied  for  surgical  treatment,  but  instead  was 
treated  daily  with  x-rays  for  half  an  hour.  After  the  second 
day  the  patient  had  no  more  pain  and  required  no  more  mor- 
phin.  On  the  sixth  day  he  had  a  very  slight  attack.  Some 
time  after  the  pain  recurred,  but  to  what  extent  is  not  known. 

In  view  of  the  marked  analgesic  effect  of  x-rays  on  the  pain 
accompanying  malignant  growths  there  is  some  ground  for 
giving  it  a  trial  in  intractable  forms  of  neuralgia. 

Rheumatism. — A  number  of  writers  have  reported  favorable 
effects  of  x-rays  in  relieving  the  pain  of  rheumatism. 

Sokolow  *  has  reported  four  cases:  Case  1,  a  girl  nine  years 
of  age,  with  articular  rheumatism  of  the  hands  and  knees 
accompanied  by  severe  pain  and  pronounced  swelling.  The 
pain  vanished  after  two  exposures.  In  two  other  similar  cases 
the  pain  disappeared  after  one  and  four  exposures  respectively. 
Case  4,  a  girl  thirteen  years  old,  with  chronic  rheumatism 
accompanied  by  severe  pain  and  swelling  of  the  knee,  was 
greatly  improved  under  x-ray  exposures.  Stenbeck  f  has 
reported  fifty-two  cases  of  chronic  rheumatism  treated  by 
x-ray  exposures.  Forty  per  cent,  were  clearly  improved; 
forty  per  cent,  were  subjectively  better;  twenty  per  cent,  were 
uninfluenced.  Escherich  de  Graz  J  reports  that  "quite  recently 
I  have  had  occasion  to  note  the  very  marked  analgesic  power 
of  the  x-rays  upon  the  pain  of  a  child  suffering  from  rheumatic 
polyarthritis." 

Pruritus. — The  attempt  has  also  been  made  to  utilize  the 
analgesic  properties  of  x-rays  in  the  treatment  of  pruritus. 

Scholtz  §  has  seen  decided  improvement  result  from  the  use 
of  x-rays  in  a  case  of  pruritus  vulvse,  and  Sjogren  and  Seder- 
holm  ||  have  reported  the  relief  of  pruritus  vulva3  in  seven  cases 
which  were  given  x-ray  exposures. 

The  effect  of  x-rays  in  relieving  itching  is  unquestionable, 
and  the  method  deserves  a  trial  in  the  treatment  of  the  intract- 

*Russky  Vratch,  1897,  No.  46;  Abstr.  Fortschritte  a.  d.  Geb.  d.  Rontgen- 
strahlen,  1898,  i,  p.  209. 

t  Fortschritte  a.  d.  Geb.  d.  Rontgenstrahlen,  1898,  ii,  p.  227. 

J  Revue  des  maladies  de  1'enfance,  1898,  xvi,  p.  242. 

\  Arch.  f.  Derm.  u.  Syph.,  1902,  lix,  p.  421. 

||  Fortschritte  a.  d.  Geb.  d.  Rontgenstrahlen,  1901,  iv,  p.  145. 


558  PSEUDO-LEUKEMIA    AND    OTHER    AFFECTIONS. 

able  cases  of  pruritus  vulvae  and  ani,  as  well  as  in  the  inflam- 
matory dermatoses  accompanied  by  intractable  itching. 

Goitre. — Williams  *  has  reported  improvement  in  a  case  of 
exophthalmic  goitre  treated  with  x-rays,  and  Campbell  f  has 
reported  the  improvement  of  a  simple  goitre  in  a  patient  who 
was  having  exposures  for  acne. 

Brook,  I  on  the  other  hand,  has  reported  the  case  of  a  patient 
who  had  carcinoma  of  the  breast  and  a  goitre,  which  was  ex- 
posed, together  with  the  carcinoma,  to  the  x-rays.  The  car- 
cinoma was  symptomatically  cured  while  the  goitre  was  un- 
affected. 

My  experience  in  goitre  includes  three  cases  which  have  had 
fairly  vigorous  treatment : 

Case  154. — An  exophthalmic  goitre  which,  after  moderate 
exposures,  showed  no  result. 

Case  155. — A  simple  goitre,  after  vigorous  exposures  extending 
over  two  and  a  half  months  and  carried  to  the  point  of  producing 
marked  pigmentation,  showed  no  effect. 

In  another  patient  who  had  a  goitre  on  one  side  that  was 
exposed  persistently  to  x-rays  while  a  carcinoma  of  the  breast 
was  being  treated  (Case  80)  there  has  been  considerable  diminu- 
tion in  the  size  of  the  goitre. 

That  x-rays  will  prove  of  benefit  in  goitre  is  yet  to  be  deter- 
mined. Nevertheless  the  results  in  glandular  hyperplasias  and 
in  some  cases  of  scar  tissue  yet  to  be  referred  to  are  sufficiently 
positive  to  give  ground  for  a  further  trial  of  the  method  in 
goitre. 

Scars. — Theoretically  the  use  of  x-rays  would  hardly  be 
expected  to  be  effective  against  healthy  scar  tissue,  since  it 
has  practically  the  same  powers  of  resistance  as  normal  tissue. 
A  marked  favorable  effect,  however,  has  been  observed  upon 
the  unhealthy  scars  of  lupus  which  have  been  treated  with 
x-rays,  and  as  a  result  its  use  for  the  removal  of  scars  has  been 
suggested  by  Ullman§;  and  Hahn  and  Albers-Schonberg,  ||  Tay- 

*"The  Rontgen  Rays  in  Medicine  and  Surgery,"  p.  679. 

t  Jour.  Am.  Med.  Assoc..  1902,  xxxix,  p.  313. 

JBrit.  Med.  Jour.,  1902,  ii,  p.  1303. 

\  Wien.  med.  Presse,  1900,  xli,  p.  954. 

||  Munch,  med.  Wochens.,  1900,  xlvii.  pp.  284,  324,  363. 


SCARS.  559 

lor,*  and  Harris  f  have  reported  the  removal  of  scars  by  this 
method.  This  application  of  the  method  was  suggested  to  me 
by  the  marked  improvement  in  the  apparently  healthy  scars 
of  my  Case  34  of  lupus  treated  by  x-rays,  and  I  have  used  the 
method  successfully  in  one  very  thick  keloid : 

Case  156. — Boy  aged  ten  years,  referred  to  me  by  Dr.  D.  A.  K. 
Steele.  A  keloid  formed  several  years  ago  on  a  vaccination 
scar,  and  another  upon  a  scar  on  the  helix  of  his  left  ear.  These 
were  removed  and  promptly  recurred.  The  keloid  on  the  arm 
(Fig.  172)  was  a  typical  keloid  two  and  a  half  inches  long,  three- 
fourths  of  an  inch  broad,  and  at  least  half  an  inch  thick.  Each 
of  the  stitch  scars  around  this  showed  a  keloid  about  the  size 
of  a  marrowfat  pea.  The  keloid  on  the  ear  was  a  curious- 
looking  globular  tumor  about  an  inch  in  diameter,  purplish  in 
color,  with  dilated  blood-vessels  coursing  over  it,  and  had 
grown  rapidly.  It  resembled  to  an  alarming  extent  a  sarcoma. 
The  x-ray  exposures  were  begun  over  the  keloid  on  the  arm 
in  December,  1900,  but  the  patient's  attendance  was  desultory, 
and  with  a  moderate  amount  of  treatment  no  effect  was  pro- 
duced. It  was  not  until  after  80  exposures  had  been  given, 
extending  over  seven  months,  that  any  effect  was  produced. 
In  July  and  August,  1901,  however,  I  carried  the  treatment  to 
the  point  of  producing  a  very  acute  dermatitis  with  the  forma- 
tion of  a  superficial  necrotic  membrane.  This  healed  over  in 
three  weeks,  and  from  that  time,  September,  1901,  the  keloid 
rapidly  shrunk.  It  had  practically  disappeared  by  November  1, 
1901.  The  difference  at  that  time  is  shown  in  figure  173.  The 
entire  keloid  had  disappeared  except  for  a  slight  ridge  down 
the  center  of  the  scar.  It  seemed  to  me  two  or  three  months 
later  without  further  treatment  that  there  was  a  slight  tendency 
toward  thickening  of  the  keloid,  and  I  was  apprehensive  of  the 
recurrence  of  the  growth.  Since  September,  1901,  however,  this 
lesion  has  had  practically  no  treatment,  and,  contrary  to  my 
apprehension,  it  has  steadily  improved,  so  that  at  the  present 
time  there  is  no  thickening  of  the  tissue  left.  The  little  ridge 
that  extended  down  the  center  has  disappeared  and  the  whole 

*Brit.  Med.  Jour.,  1901,  ii,  p.  853. 

t  Australasian  Med.  Gazette,  1901,  xx,  p.  133. 


560  PSEUDO-LEUKEMIA    AND    OTHER    AFFECTIONS. 

area  is  soft  and  pliable  and  thin  (Fig.  174).  This  steady  im- 
provement for  a  year  seems  to  give  good  grounds  for  expecting 
a  permanent  success. 

The  keloid  on  the  ear  (Fig.  175)  has  been  on  two  occasions 
exposed  to  x-rays  to  the  point  of  producing  a  marked  vesicular 
dermatitis,  with  the  result  that  it  has  shrunk  to  about  one-half 
its  previous  size  (Fig.  176).  It  is  still  under  somewhat  irregular 
treatment  and  there  seems  good  reason  to  expect  a  successful 
result. 

Judging  from  the  result  in  this  case,  no  scar  tissue  is  too 
well  developed  to  render  success  impossible,  and  the  method 
should  be  given  a  persistent  trial  in  such  cases.  The  fact  that 
results  were  not  gotten  in  this  case  from  six  months  of  moderate 
treatment  and  then  were  obtained  by  vigorous  pushing  of  the 
exposures  is  instructive. 

Elephantiasis. — Mascat  *  showed  at  the  Academy  of  Science, 
Paris,  February,  1898,  a  series  of  photographs  of  a  patient 
suffering  from  elephantiasis  who  had  recovered  under  a  few  x-ray 
exposures. 

Callous  Sinuses. — Hart  f  has  reported  a  case  of  abdominal 
sinus  five  to  six  inches  long,  which  had  refused  to  heal  after 
several  wreeks  of  gauze  plugging,  and  which  after  an  exposure 
for  x-ray  photograph  cicatrized  almost  immediately.  A  second 
case  where  sinuses  had  existed  for  months  was  given  three 
exposures  with  prompt  healing. 

Chronic  Ulcers. — Sjogren  and  Sederholm  J  have  reported  four 
cases  of  sluggish  indurated  ulcers  which  had  resisted  ordinary 
methods  of  treatment  and  which  healed  under  the  stimulation 
of  x-ray  exposures. 

I  have  seen  similar  beneficial  results  from  x-ray  exposures  in 
several  indolent  ulcers,  including  one  varicose  ulcer.  In  chronic 
indolent  ulcers  doubtless  x-ray  exposures  may  be  valuable  in 
furnishing  the  stimulation  that  is  at  times  a  necessary  part  of 
the  treatment  of  such  lesions. 

Naevus. — The  removal  of  hair  from  hairy  nsevi  was  successfully 

*  Lancet,  1898,  i,  p.  544.  fBrit.  Med.  Jour.,  1902,  i,  p.  1330. 

JFortschr.  a.  d.  Geb.  d.  Rontgenstrahlen,  1901,  iv,  p.  145. 


561 


5(53 


VASCULAR   NyEVI.  565 

accomplished  by  Freund  *  in  his  first  case  of  hypertrichosis 
treated  by  this  method. 

I  have  treated  one  case  of  hairy  nsevus  of  the  forehead  of 
a  young  child  with  what  bid  fair  to  be  excellent  permanent 
results. 

Case  157. — Child,  aged  two  years,  with  a  pigmented  nsevus 
on  the  forehead  covered  with  a  profuse  growth  of  long,  black 
hair.  Under  persistent  treatment  extending  over  six  months 
the  hair  and  almost  all  of  the  pigmentation  and  hyperkeratosis 
were  removed,  so  that  the  skin  is  now  smooth  and  soft  and 
almost  of  normal  color.  The  hair  has  been  absent  now  for 
four  months  and  shows  no  tendency  to  return.  There  is  in 
my  opinion  little  room  for  doubt  that  x-rays  will  furnish  a 
successful  method  of  dealing  with  many  cases  of  pigmented 
and  hairy  nsevi. 

Vascular  Naevi. — Jutassy  f  has  given  a  very  interesting  report 
of  the  successful  treatment  of  an  extensive  vascular  nsevus  of 
the  face.  Over  part  of  the  area  involved  the  nsevus  was  flat, 
but  on  the  cheek  and  nose  there  were  dilatations  forming  angio- 
mata  from  the  size  of  a  hemp-seed  to  that  of  a  bean.  The 
exposures  in  this  case  were  carried  to  the  point  of  producing 
a  very  acute  dermatitis  with  free  vesiculation.  As  a  result  the 
nsevus  was  practically  destroyed.  There  remained  over  the 
area  a  soft  smooth  scar  of  almost  normal  color.  There  was  no 
trace  of  angioma  left.  A  year  and  a  half  later  the  improvement 
had  been  maintained. 

I  have  treated  part  of  a  flat  vascular  nsevus  of  the  face  and 
neck  by  this  method. 

Case  158. — Miss .  Exposures  in  this  case  were  made 

experimentally  over  an  area  on  the  side  of  the  neck  the  size 
of  a  silver  dollar,  and  they  were  carried  to  the  point  of  pro- 
ducing an  acute  dermatitis,  upon  the  subsidence  of  which  there 
was  marked  improvement  in  the  color.  This  improvement  has 
been  maintained.  The  exposed  area  is  much  paler  than  the 
rest  of  the  nsevus  and  evidently  a  large  number  of  telangiectases 
have  been  destroyed. 

*Wien.  med.  Wochens.,  1897,  xlvii,  p.  428. 
fPest.  med.-chir.  Presse,  1900,  xxxvi,  p.  73. 


566  PSEUDO-LEUKEMIA    AND   OTHER  AFFECTIONS. 

It  is  possible  that  by  setting  up  an  acute  reaction  in  a  vascular 
mevus  there  may  be  produced  scar  tissue  that  will  be  of  such 
a  character  as  practically  to  destroy  the  lesions.  Of  course,  the 
likelihood  of  doing  this  is  greater,  the  less  the  dilatation  of  the 
blood-vessels.  It  is  almost  surely  true  that  where  there  are 
large  angiomata  the  method  will  not  be  very  effective,  although 
Jutassy's  case  seems  to  show  that  it  may  be  possible  to  deal 
with  superficial  angiomata. 

Verruca. — Scholtz  *  and  Sjogren  and  Sederholm  f  have  re- 
ported the  disappearance  of  warts  under  x-ray  exposures  without 
the  production  of  marked  reaction  in  the  tissues.  I  have 
myself  seen  several  warts  disappear  from  the  face  while  patients 
were  having  treatment  for  other  purposes. 

Clavus. — Zeisler  in  a  personal  communication  has  reported 
the  disappearance  of  soft  corns  on  the  bottom  of  the  feet  under 
a  few  exposures.  The  case  was  one  in  which  the  development 
of  keratoderma  on  the  soles  was  so  severe  as  to  interfere  very 
greatly  with  walking.  Relief  was  complete. 

Senile  Verruca. — In  considering  the  treatment  of  cutaneous 
carcinoma  I  have  called  attention  to  the  cure  of  patches  of 
senile  keratosis  on  the  faces  of  four  patients  (Cases  64,  66,  69, 
70).  In  all  of  these  cases  several  patches  of  senile  keratosis 
were  successfully  treated.  The  results  in  these  cases  were  ideal, 
and  seem  to  indicate  that  in  the  use  of  x-rays  we  have  found 
a  much-needed  method  of  successfully  getting  rid  of  these 
lesions.  In  these  cases  I  have  used  the  method  not  only  in 
patches  which  showed  beginning  precancerous  changes,  but  also 
in  patches  whose  bases  showed  no  evidence  of  inflammatory 
changes  whatever.  There  has  been  manifest  thus  far  in  my 
cases  no  tendency  whatever  to  recurrence  of  the  senile  patches. 

Leucoma. — Williams  J  has  attempted  to  remove  scars  of  the 
cornea  by  exposing  the  cornea  to  x-rays.  In  one  case  of  leucoma 
which  he  treated  there  has  been  considerable  improvement  in 
the  patient's  condition.  The  method  is  perhaps  worthy  of 
trial,  but  it  is  not  in  my  opinion  free  from  danger. 

*  Arch.  f.  Derm.  u.  Syph.,  1902,  lix,  p.  421. 

fFortschr.  a.  d.  Geb.  d.  Riintgenstrahlen,  1901,  iv,  p.  145. 

J  "The  Rontgen  Rays  in  Medicine  and  Surgery,"  p.  <>71J. 


CHAPTER  XVII. 
GENERAL  CONCLUSIONS. 

Non-malignant  Diseases. — A  consideration  of  the  entire  subject 
of  radiotherapy  in  its  present  stage  of  development  seems  to 
leave  no  room  for  doubt  that  we  have  in  it  a  valuable  addition 
to  the  means  at  our  command  for  combating  disease.  The 
method  has  more  than  justified  its  small  beginnings  five  years 
ago,  and  at  the  present  time  it  bids  fair  to  revolutionize  the 
methods  of  treatment  of  certain  affections.  One  of  the  greatest 
values  of  the  method  lies  in  the  fact  that  it  is  applicable  to 
certain  groups  of  diseases  which  have  hitherto  been  classed 
among  the  most  intractable  with  which  we  have  to  deal.  This 
applies  not  only  to  its  use  in  malignant  diseases,  but  to  its 
use  in  certain  less  grave  affections  which  have  been  the  trial 
and  the  bane  of  dermatology. 

That  the  use  of  x-rays  is  a  valuable  addition  to  the  methods 
at  our  command  for  treating  hypertrichosis,  acne,  and  sycosis 
there  seems  no  question;  and  that  in  itself  is  no  small  gain 
to  dermatology.  Its  use  in  tinea  tonsurans  and  favus  is  less 
well  established,  but  is  unquestionably  worthy  of  persistent 
trial.  In  the  treatment  of  certain  intractable  forms  of  eczema, 
lichen  planus,  and  psoriasis  there  seems  good  reason  to  believe 
that  the  method  has  a  distinct  field  of  usefulness.  Its  value  in 
lupus  erythematosus  is  not  yet  well  established.  Its  value  in 
lupus  vulgaris  is  above  question.  This  method  and  Finsen's 
method  of  treating  lupus  with  ultra-violet  light  have  inaugurated 
a  new  period  in  the  treatment  of  that  most  intractable  and 
distressing  affection. 

Were  the  entire  field  of  usefulness  of  radiotherapy  embraced 
in  the  treatment  of  the  affections  briefly  referred  to  above,  the 
agent  would  bean  addition  to  our  therapeutic  armamentarium  of 
no  mean  proportions.  The  above,  however,  takes  no  account  of 

567 


568  GENERAL   CONCLUSIONS. 

its  application  on  malignant  diseases,  in  which  unquestionably 
it  has  its  greatest  field  of  usefulness. 

Malignant  Diseases. — Upon  such  a  topic  as  the  value  of  x-rays 
or  any  other  agent  in  the  treatment  of  malignant  diseases, 
conclusions  must  be  drawn  with  the  greatest  reservation,  but 
with  the  experience  now  at  our  command  certain  facts  may 
be  said  to  be  established. 

First:  Under  the  influence  of  x-rays  alone,  carcinomata  can 
be  made  to  disappear  and  can  be  replaced  by  healthy  tissue. 
This  is  established  not  only  clinically,  but  also  by  microscopic 
studies.  Such  a  disappearance  of  a  malignant  growth  is  a  new 
fact.  It  gives  us  a  method  of  treating  malignant  growths  essen- 
tially new  in  principle.* 

The  theoretical  advantages  which  the  method  offers  are: 

(a)  It  is  painless.  It  avoids  the  ordeal  of  operations,  a  fact 
of  importance  for  a  large  number  of  the  patients  of  this  class. 

(6)  Under  proper  conditions  it  destroys  diseased  tissue  but 
leaves  the  healthy  tissue  in  its  place.  Accordingly,— 

(c)  It  leaves  small  scars,  and — 

(d)  It  can  be  used  in  cases  where  the  surrounding  healthy 
tissue  cannot  be  sacrificed.     This  means  that— 

(e)  It  is  valuable  in  certain  cases  in  which  ordinary  methods 
are  objectionable,  because  they  involve  extensive  operations  and 
serious  subsequent  disfigurement ;  as,  for  example,  about  the  eye 
and  nose.     This  means  further  that — 

( /)  It  has  a  field  of  usefulness  in  cases  in  which  ordinary 
methods  are  impossible,  because  of  the  amount  of  destruction 
of  tissue  which  complete  removal  would  require.  In  other 
words,  it  is  applicable  to  some  inoperable  cases. 

(g)  It  is  not  only  painless,  but  it  usually  has  a  marked  ano- 
dyne effect  in  painful  malignant  diseases. 

The  extent  of  application  and  the  limitations  of  the  method 
are  not  yet  determined.  In  cutaneous  carcinoma  without 

*In  speaking  of  this  method  as  essentially  new  in  principle,  the  use  of  ultra- 
violet light  must,  of  course,  not  be  overlooked.  That  also  is  essentially  new 
in  principle,  but  it  and  .r-rays,  as  I  have  previously  undertaken  to  show,  in- 
volve essentially  the  same  therapeutic  principle,  so  that  wherever  I  speak  of  the 
use  of  x-rays  in  a  connection  where  ultra-violet  light  might  be  used  I  mean  to 
include  it  in  my  comparison  or  my  statement. 


MALIGNANT   DISEASES.  569 

metastasis  the  method  has  a  list  of  well-established  successfully 
treated  cases,  sufficient  to  give  it  standing  in  comparison  with 
any  other  method  of  treating  such  lesions.  Even  for  cases 
which  are  entirely  amenable  to  ordinary  methods  of  treatment, 
such  as  small  epitheliomas,  the  method  may  challenge  com- 
parison of  its  results  with  those  obtained  in  any  other  way. 
It  has  the  advantage  of  producing  a  minimum  of  scarring  and 
thus  giving  cosmetic  results  that  are  unapproachable  by  any 
other  method. 

In  inoperable  growths  upon  the  surface  the  method  has  a 
very  considerable  number  of  not  only  brilliant  but  amazing 
results  to  its  credit.  These  results  have  been  attained  not 
only  in  growths  which  are  entirely  on  the  surface,  but  in  num- 
erous cases  the  results  establish  the  fact  that  the  effect  may 
be  obtained  several  inches  beneath  the  surface ;  as,  for  example, 
Cases  75,  95,  97,  98,  119,  128,  132,  148,  and  149  in  my  list. 
As  to  the  effect  upon  malignant  growths  which  involve  the 
cavities  of  the  body,  the  standing  of  the  method  is  not  yet 
established.  There  are  some  facts  which  give  us  reason  for 
encouragement  in  these  cases.  Pain  can  be  controlled,  and 
there  is  reason  to  believe  that  in  some  cases — as,  for  example, 
Cases  104  and  121  in  my  list — malignant  growths  situated  in 
the  cavities  of  the  body  can  be  checked  in  their  course  and 
perhaps  reduced  in  size  by  the  methods  of  applying  z-rays 
already  at  our  command.  And  the  results  in  some  cases, 
including  a  few  cases  in  the  cavities  of  the  body,  as  my  Case 
119  with  carcinoma  within  the  cranium,  have  been  so  surprising 
that  they  give  encouragement  for  the  persistent  trial  of  this 
method  in  the  most  desperate  cases.  This  is  the  more  true 
because  in  the  cases  which  we  are  now  considering  the  method 
is  not  poaching  upon  the  preserves  of  any  other  method  of 
treatment  that  offers  any  hope  of  relief  of  any  sort.  These 
are  cases  which  have  been  hitherto  entirely  beyond  hope. 

When  we  come  to  the  treatment  of  operable  malignant 
growths  the  responsibility  for  advocating  the  use  of  rr-rays 
becomes  greater.  In  cutaneous  carcinomata  there  are  good 
grounds  for  the  advocacy  of  x-rays  in  place  of  other  methods 
of  treatment.  The  method  has  advantages  which  in  my  opinion 


570  GENERAL   CONCLUSIONS. 

entitle  it  to  rank  as  the  method  of  preference  in  the  treatment 
of  epitheliomata.  When  it  comes  to  more  extensive  forms  of 
operable  malignant  growths,  particularly  growths  where  the 
dangers  of  metastasis  are  imminent,  and  therefore  the  question 
of  time  very  important — as,  for  example,  in  carcinomata  of  the 
breast — the  situation  is  different.  Our  experience  with  x-rays 
is  not  sufficient  to  warrant  us  in  relying  upon  this  method  alone 
in  such  cases.  Were  the  results  of  surgical  intervention  in  such 
cases  better,  the  advocacy  of  x-rays  as  a  substitute  would  cer- 
tainly not  be  justified;  but  even  unsatisfactory  as  they  are, 
we  are  not  justified  in  refusing  to  avail  ourselves  of  the  benefits 
which  surgery  offers  in  suitable  cases.  This  is  the  more  true 
because  by  availing  ourselves  of  surgery,  we  are  not  cut  off 
from  the  use  of  x-rays  at  the  same  time. 

Prophylactic  Use  of  X-rays. — On  the  other  hand,  I  believe 
the  argument  for  operation  in  suitable  cases  is  no  stronger 
than  the  argument  for  the  use  of  x-rays  in  conjunction  with 
surgery  in  these  same  cases,  and  that  with  the  present  knowledge 
before  us  the  man  who  operates  and  refuses  to  avail  himself 
of  the  advantages  of  x-rays  is  in  as  illogical  a  position  as  the 
man  wrho  uses  x-rays  in  such  cases  and  refuses  to  avail  himself 
of  the  possible  benefits  of  operation.  The  combination  of  the 
two  methods  of  treatment  may  be  logically  claimed  in  my 
opinion  as  the  proper  procedure  in  cases  which  are  suitable 
for  operation.  With  the  fact  before  us  as  to  the  effect  of  x-rays 
upon  palpable  malignant  infiltrations,  the  use  of  x-rays  as  a 
means  of  prophylaxis  subsequent  to  operations  for  malignant 
growths  may  be  urged  as  a  necessary  measure,  if  patients  are 
to  be  given  the  best  possible  chance  of  escaping  recurrence. 

Use  of  X-rays  Preliminary  to  Operations. — The  use  of  x-rays 
may  be  urged  also  as  a  method  of  preliminary  treatment  of 
malignant  growths  when  for  any  reason,  as  while  waiting  to 
get  a  patient  in  condition,  it  is  necessary  to  postpone  operation. 
There  are  good  reasons  to  hope  that  by  such  preliminary  ex- 
posures many  malignant  growths  may  be  checked  in  their 
course,  so  that  the  patient  under  exposures  would  not  be  losing 
ground  while  waiting  for  operation. 

Permanency  of  Results. — As  to  the  permanency  of  the  results 


LENGTH  OF  TREATMENT  OF  SUCCESSFUL  CASES.         571 

produced  by  x-rays,  our  experience  is  not  sufficiently  long  to 
justify  any  dogmatic  claims.  In  epithelioma  I  am  willing  to 
hazard  the  opinion,  from  the  character  of  the  scars,  that  the 
results  will  not  show  an  undue  proportion  of  recurrences.  As 
to  the  permanency  of  results  after  the  symptomatic  cure  of 
inoperable  malignant  growths,  or  growths  which  offer  large 
possibilities  of  metastases,  it  would  be  manifestly  absurd  for 
any  one  to  make  dogmatic  claims  for  either  this  method  or  any 
other. 

Length  of  Treatment  of  Successful  Cases. — The  question 
naturally  arises  as  to  how  long  treatment  should  be  continued 
after  apparent  cure  of  these  growths.  In  favorable  cases  of 
epithelioma,  cases  in  which  every  point  of  the  scar  is  above 
suspicion,  it  is  not  my  practice  to  continue  treatment  after 
a  healthy  scar  is  obtained.  All  such  cases,  however,  are  if 
possible  kept  under  frequent  observation,  as  they  would  be 
after  any  other  method  of  treatment.  In  all  cases  which  are 
grave,  or  in  which  there  is  a  likelihood  of  the  development 
of  metastasis,  I  advise  the  repetition  of  series  of  exposures, 
each  series  sufficiently  long  to  cause  evidence  of  reaction.  For 
example,  after  a  recurrent  carcinoma  of  the  breast  has  been 
symptomatically  cured,  it  would  seem  advisable  to  have  the 
treatment  repeated  at  intervals  for  at  least  three  years.  It  is 
generally  assumed  that  a  malignant  growth  cannot  be  accepted 
as  cured  until  three  years  have  passed  after  its  disappearance 
without  recurrence.  It  would  seem  a  necessary  corollary  of 
that  assumption,  then,  that  prophylactic  treatment  for  the 
prevention  of  recurrence  should  be  continued  for  at  least  three 
years.  The  proper  procedure  would  seem  to  be  to  give  a 
series  of  exposures  at  least  two  or  three  times  a  year,  the  expo- 
sures to  be  carried  to  the  point  of  producing  a  reaction.  By 
such  a  course  we  have  the  best  chance  of  destroying  any 
budding  focus  of  disease  before  it  has  amounted  to  a  palpable 
recurrence. 

Reasons  for  Different  Results  in  Similar  Cases. — The  question 
naturally  arises  as  to  the  reason  for  the  different  results  in 
similar  cases  of  malignant  growths,  and  one  is  led  to  speculate 
at  once  as  to  whether  there  is  not  a  difference  in  susceptibility 


572  GENERAL    CONCLUSIONS. 

to  x-rays  of  different  forms  of  carcinoma  and  sarcoma.  There 
are  no  data  available  at  present  upon  this  subject.  The  knowl- 
edge of  the  histological  character  of  the  cases  that  have  been 
treated  is  too  meager  to  allow  of  any  deductions  upon  this 
point.  Were  the  material  available  from  which  to  make  a 
study  of  the  relative  susceptibility  to  x-rays  of  different  forms 
of  malignant  growths,  it  is  likely  that  highly  interesting  facts 
would  be  discovered.  The  explanation  of  the  difference  in  sus- 
ceptibility to  x-rays  in  different  cases  of  malignant  disease 
will  be  found,  in  my  opinion,  to  depend  upon  two  facts:  first, 
the  difference  in  susceptibility  of  different  forms  of  malignant 
growths  and  second,  a  similar  difference  in  susceptibility  of 
different  individuals. 

Effect  of  X-ray  Exposures  on  General  Health. — The  improve- 
ment in  general  health  of  patients  with  malignant  growths  under 
treatment  with  x-rays  is  a  notable  fact  in  many  cases,  and 
is  the  best  possible  evidence  of  the  radical  effect  upon  the 
disease.  A  marked  improvement  is  seen  in  many  cases,  and  is 
usually  observed  when  the  malignant  tumors  are  subsiding 
under  x-ray  exposures.  This  goes  very  far  to  refute  the  state- 
ment that  it  is  dangerous  to  cause  a  rapid  absorption  of  a 
large  malignant  growth,  on  account  of  the  danger  of  toxemia 
from  absorption  of  the  products  of  this  destructive  process. 
In  the  many  cases  of  malignant  disease  in  which  I  have  ob- 
served the  rapid  disappearance  of  tumor  masses  I  have  never 
seen  any  suspicion  of  acute  toxemia.  A  few  patients,  how- 
ever, have  complained  of  articular  rheumatic  pains  while  tumors 
were  subsiding,  and  this  has  occurred  with  sufficient  frequency 
to  lead  me  to  suspect  that  perhaps  it  was  in  part  due  to  the 
presence  in  the  system  of  the  products  of  degeneration.  Other 
observers  have  called  attention  to  the  same  fact.  Aside  from 
this  altogether  insignificant  trouble,  I  have  never  seen  any 
effect  that  might  be  attributed  to  intoxication.  And  nothing 
has  happened  in  my  experience  to  lessen  my  desire  to  cause 
the  destruction  of  these  tumors  as  quickly  as  possible.  As  a 
rough  guess,  I  should  say  this  complaint  of  rheumatic  pains 
has  occurred  in  less  than  5  per  cent,  of  the  cases  in  which  I 
have  seen  large  masses  of  malignant  growths  subsiding  under 
x-ray  exposures. 


EFFECTS   ON   THE    BLOOD.  573 

Sterne  *  has  reported  a  case  in  which  there  was  an  acute 
toxemia  resembling  an  acute  sepsis  that  he  thinks  was  due  to 
the  liberation  of  toxins  in  the  destruction  of  large  masses  of 
glandular  tissue.  The  case  was  one  of  enormous  enlargement 
of  many  glands,  probably  a  leukemia  or  a  pseudo-leukemia. 
Under  x-rays  the  enlarged  glands  decreased  until  they  had 
disappeared  altogether.  The  spleen  and  liver  enlarged,  the 
spleen  finally  reaching  down  to  the  rim  of  the  pelvis.  With  the 
disappearance  of  the  tumors  the  apparently  septic  condition 
developed.  The  patient  finally  passed  into  coma.  "Convul- 
sions set  in,  and  he  died  with  every  mark  of  violent  sepsis, 
not  only  clinically  but  microscopically,  demonstrable  through 
blood  changes." 

One  of  my  cases  of  leukemia,  which  is  described  in  detail  on 
page  552,  had  a  similar  attack  after  the  subsidence  of  his  glands 
under  x-rays,  but  he  had  the  same  sort  of  attacks  before  ever 
coming  under  x-rays,  and  he  died  in  such  an  attack  at  a  time 
when  he  had  not  been  having  x-ray  exposures  for  six  weeks, 
and  when  there  was  no  reasonable  ground  for  believing  that 
his  attack  had  any  connection  with  any  toxic  substances  lib- 
erated in  the  disappearance  of  his  tumors  under  x-rays.  The 
evidence  in  these  cases,  therefore,  is  not  conclusive,  and  there 
are  no  other  cases  in  the  literature  which  justify  the  assumption 
that  an  acute  toxemia  can  be  produced  by  the  absorption  of 
products  set  free  in  the  disintegration  of  tumor  masses  under 
x-ray  exposures.  I  have  had  numerous  opportunities  of  seeing 
large  masses  of  carcinoma  and  sarcoma  disappear  under  x-ray 
exposures  and  have  never  seen  any  symptoms  of  an  accompany- 
ing acute  toxemia. 

Effects  on  the  Blood. — Friend,f  in  a  preliminary  note,  has 
reported  that:  "While  treating  patients  with  the  Rontgen  rays, 
I  observed  in  a  case  of  inoperable  cancer  of  the  breast  and  in 
a  case  of  intra-abdominal  sarcoma,  as  one  of  the  effects  of 
treatment,  a  great  increase  of  erythrocytes  and  a  great  diminu- 
tion of  leucocytes." 

I  have  examined  the  blood  in  a  number  of  cases  of  malignant 

*  Indiana  Med.  Jour.,  1902,  xxi,  p.  56. 
|  American  Medicine,  1902,  iv,  p.  11. 


574  GENERAL   CONCLUSIONS. 

growth  which  were  subsiding  under  x-ray  exposures  without 
finding  any  peculiar  characteristics.  The  erythrocytes  have 
been  counted  in  at  least  a  dozen  cases  of  carcinoma,  and  in 
two  or  three  cases  of  sarcoma.  There  has  always  been  some 
diminution  in  the  erythrocytes,  and  never  a  marked  increase. 
The  diminution  has  been  such  as  would  be  expected  hi  patients 
in  the  physical  condition  that  these  patients  usually  present. 
I  have  made  differential  counts  of  the  white  blood-corpuscles 
in  several  cases  of  carcinoma,  in  which  at  the  time  tumors 
were  subsiding  under  x-ray  exposures.  None  of  these  counts 
has  shown  anything  unusual. 

Coley  *  has  also  made  a  count  of  the  red  blood-cells  and  a 
differential  count  of  the  white  cells  in  three  cases  of  sarcoma 
when  the  tumor  was  decreasing  in  size  under  x-rays.  His 
counts  also  show  nothing  unusual.  Coley 's  findings  and  mine, 
therefore,  discover  no  peculiar  changes  in  the  blood  while 
malignant  tumors  are  being  absorbed  under  x-ray  exposures, 
and  do  not  confirm  the  increase  hi  the  red  cells  and  the  decrease 
in  the  whites  which  Friend  found  in  his  case. 

Danger  of  Metastasis  Under  X-ray  Exposures. — It  has  also 
been  suggested  that  in  the  treatment  of  a  malignant  tumor 
with  x-rays  the  danger  of  the  development  of  metastases  may 
be  increased  on  account  of  the  reaction  produced  by  the  x-rays. 
Were  the  inflammatory  process  produced  by  x-rays  in  a  mass 
of  carcinoma,  for  example,  a  simple  inflammatory  process, 
there  would  be  more  grounds  perhaps  for  this  fear.  But  this 
is  not  the  situation;  in  the  first  place,  it  is  not  necessary  to 
get  up  a  marked  inflammatory  reaction  in  order  to  destroy  the 
carcinoma  cells  in  most  instances;  and,  in  the  second  place, 
when  a  marked  reaction  is  produced,  this  is  not  a  reaction 
accompanied  by  exuberant  growth  of  the  carcinoma  cells  as  a 
result  of  increased  blood-supply.  On  the  contrary,  when  such 
a  reaction  is  produced  in  a  mass  of  carcinoma  cells,  there  is 
not  only  not  created  a  favorable  situation  for  the  growth  of 
the  carcinoma,  but  there  is  created  a  situation  of  which  the 
most  salient  characteristic  is  the  destructive  process  that  takes 
place  in  these  cells.  The  two  characteristic  histological  changes 

*  American  Medicine,  1902,  iv,  p.  251. 


OTHER    TREATMENT   IN    CONJUNCTION    WITH    X-RAYS.       575 

of  the  process  are  degenerative  changes  in  the  cells  of  the  malig- 
nant tissue — this  change  beginning,  too,  in  the  youngest  cells 
at  the  periphery — and  obliterative  endarteritis  of  the  vessels  of 
the  part,  certainly  not  changes  that  are  conducive  to  the  pro- 
liferation of  the  growth.  It  is  hard  to  see  how  a  process  which 
readily  destroys  carcinomatous  tissue  in  this  way  can  at  the 
same  time  render  the  danger  of  proliferation  greater.  The  clini- 
cal data  at  our  command  are  not  sufficient  to  furnish  any 
evidence  upon  this  point,  but  as  far  as  they  go  they  lend  no 
weight  to  the  suggestion.  Upon  theoretical  grounds  alone  there 
is,  in  my  opinion,  every  reason  to  believe  that  the  process  of 
destruction  by  x-rays  of  masses  of  carcinoma  or  sarcoma  lessens 
very  much,  rather  than  increases,  the  dangers  of  metastasis. 

Use  of  Other  Treatment  in  Conjunction  with  X-rays. — Of 
course,  there  is  no  objection  in  the  treatment  of  malignant 
growths  or  other  troubles  with  x-rays  to  the  use  of  other  methods 
of  treatment  in  conjunction  with  x-rays.  In  my  early  use  of 
x-rays,  before  the  method's  value  was  established,  I  avoided 
as  far  as  possible  all  adjuvants,  but  at  the  present  time  every- 
thing possible  is  done  to  help  along  the  recovery.  As  for  local 
treatment,  the  cases  are  given  ordinary  surgical  dressings.  It 
is  not  necessary  to  be  as  careful  of  these  dressings  as  under 
ordinary  circumstances,  because  while  under  .x-ray  exposures 
the  ulcers  almost  of  themselves  remain  sterile.  There  would 
be,  of  course,  no  objection  to  the  use  along  with  x-rays  of 
curetting  or  caustics,  or  other  such  methods  of  treatment,  were 
they  necessary;  but  in  no  case  have  I  found  the  aid  of  such 
methods  necessary.  In  one  or  two  cases  small  recurrent  or 
remaining  nodules  of  carcinoma  have  been  destroyed  by  me 
with  caustics  simply  for  convenience.  As  to  internal  treatment, 
the  patients  have  been  taken  care  of  along  ordinary  lines.  In 
all  but  superficial  carcinoma  it  is  my  practice  to  give  the  patients 
sodium  cacodylate  as  freely  as  they  can  tolerate  it,  for  the 
reason  that  there  seems  some  ground  to  believe  that  this  has 
an  inhibitory  effect  upon  the  growth  of  carcinoma,  but  no 
further  specific  medication  has  been  given  in  any  case  except 
where  it  is  mentioned  in  the  recital  of  the  cases. 


INDEX. 


ABDOMEN  and  pelvis,  fluoroscopy  of, 

121 

carcinoma  in,  x-rays  in,  509 
radiography  of,  177 
Abdominal    symptoms    from    x-ray 

exposures,  233 
tuberculosis,  x-rays  in,  396 
Acne,  x-rays  in,  caution  necessary, 

361 

rosacea,  x-rays  in,  361 
vulgaris,  x-rays  in,  352 
Actinic     properties    of    x-rays    and 

light,  similarity  of,  297 
effects  of,  on  tissues,  297 
Actinomycosis,  x-rays  in,  399 
Adams,  426 
Adenitis,  tuberculous  cervical,  x-rays 

in, 393 

Albers-Schonberg,  247,  364 
Allen,  C.  W.,  230,  399,  404.  468,  470, 

510 

Allen,  S.,  404,  506,  515 
Alopecia  areata,  x-rays  in,  349 

in  guinea-pigs,  from  x-rays,  histo- 
logical    changes    produced      in, 
250 
Aluminum     as     protective     against 

x-ray  burns,  288 

screen  in  x-ray  exposures  for  thera- 
peutic purposes,  329 
Ammeter,  88 

in  x-ray  exposures  for  therapeutic 

purposes,  320 

Amperage  and  voltage,  influence  of, 
in  x-ray  exposures  for  therapeutic- 
purposes,  310 
Andrews,  226,  446,  496 
Ankle,  radiography  of,  165 
Anode,  21 


Anodyne  effect  of  x-rays,  233,  246 

Anti-cathode,  21 

Antipyrin  ointment  in  x-ray  burns, 

334 
Anus    and    rectum,    carcinoma    of, 

x-rays  in,  513 
Appendages  of  skin,  changes  in,  from 

x-rays,  230 

diseases  of,  x-rays  in,  339 
Apps  vibrating  interrupter,  67 
Arm,  radiography  of,  160 
Atrophy  of  sweat-glands  from  x-rays 

362 

Ausset  and  Bedart,  285,  396 
Ayers,  246,  468,  469 


BABCOCK,  551 

Bacillus     of     diphtheria,     effect     of 

x-rays  on,  279 
of  tuberculosis,  effect  of  x-rays  on, 

281,  284 
of  typhoid  fever,  effect  of  x-rays 

on,  279 

Bacteria  as  cause  of  x-ray  effects,  288 
effect  of  light  upon,  299 

of  x-rays  on,  278 

in  cultures,  effect  of  x-rays  on,  278 
in  living  tissue,  effect  of  x-rays  on, 

283 

Bagge,  391 
Baldwin,  457 
Bandages,  splints,  and  plaster  casts 

in  radiography,  133 
Bang,  300 

Bario-vacuum  tube  and  regulator,  46 
Barker,  292 
Barrow,  190 
Barthelemy,  236,  247 


37 


577 


578 


INDEX. 


Basset-Smith,  280,  285 

Batteries    as    sources    of    electrical 
energy,  24 

Beck,  307,  340,  368,  404,  oil 

Beck's  technique  of  x-ray  exposures 
for  therapeutic  purposes,  307 

BeClere,  119,  175 

Becquerel,  293 

Behrend,  249 

Benedikt,  340 

Bergonie  and  Mongour,  280,  285,  397 

Berton,  279 

Bi-anode  tube,  44 

Billings,  397,  555 

Bismuth  subnitrate  ointment  as  pro- 
tective against  x-rays.  329 

Blackmarr,  271,  272 

Bladder,  stones  in,  radiography  of, 
178 

Blaise  and  Sambuc,  280,  284,  285 

Blastomycetic  dermatitis,  x-rays  in, 
399 

Blood,  effects  of  x-rays  on,  573 

Bodies,    foreign,    location    of,    with 

x-rays,  187 

location  of,  with  fluoroscope,  121 
Shenton's  method,  122 

Bond,  495 

Boric  acid  for  x-ray  burns,  333 

Bradley,  504 

Brandes,  295 

Brannon,  485 

Breakdown  in  induction  coil,  63 

Breast,  carcinoma  of,  primary,  x-rays 

in,  493 

summary,  497 
recurrent,  x-rays  in,  470 

summary,  492 
x-rays  in,  468 
tumor  of,  x-rays  in,  498 

Brennecke,  394 

Briggs,  392 

Brook,  506,  513,  558 

Bryant,  513 

Buchner,  300 

Bull,  418 

Burdick,  246.  248,  398 

Burns  in  fluoroscopy,  screens  for  pre- 
venting, 117 


Burns,  x-ray,  aluminum  as  protective 
against,  288 

care  to  avoid,  317,  344 

duration  of,  236 

electricity  producing,  291 

extent  of,  226 

incubation  period,  239 

involving    subcutaneous    tissue, 
225 

loss  of  sensibility  in,  247 

pain  in,  226 

paraffin  as  preventive  of,  288,  329 

scars  from,  226 

treatment  of,  331 

vaselin     as     protective    against, 
288,  329 

with      necrosis     of      connective 

tissue,  duration  of,  239 
Butler,  225,  332,  334 
Butler  and  Leonard.  331 
Butlin,  503 


CALAMIN  and  zinc  oxid  lotion  in  x-ray 

burns,  333 
Caldwell's     apparatus     for     making 

stereoscopic  radiographs,   191 
illuminating  device  for  examining 

negatives,  146 
liquid  interrupter,  83 
tinfoil  electroscope,  39 
tube,  328 
tube-holder,  136 
Caliper   for  locating   foreign    bodies 

with  fluoroscope,  122 
Callous  sinuses,  .r-rays  in,  560 
Campbell,  355,  502,  558 
Carcinoma,    cutaneous,    scars    after 

x-ray  treatment  of,  410,  467 
x-rays  in,  403 
deep-seated,  in  orbit,  x-rays  in,  507 

x-rays  in,  502 
in  abdomen,  x-rays  in,  509 
in  pelvis,  x-rays  in,  510 
in  thorax,  x-rays  in,  468 
of  breast,  primary,  x-rays  in,  493 

summary,  497 

recurrent,  x-rays  in,  470 

summary,  492 


INDEX. 


579 


Carcinoma  of  breast,  x-rays  in,  468 
of  esophagus,  x-rays  in,  500 
of  head,  x-rays  in,  502 
of  mouth,  x-rays  in,  506 
of  neck,  x-rays  in,  502 
of  pharynx,  x-rays  in,  506 
of  rectum  and  anus,  x-rays  in,  513 
of  stomach,  x-rays  in,  509 
of  uterus,  x-rays  in,  510,  511 
pain  in,  x-rays  in,  246 

Carcinomatous  tissue,  microscopic 
changes  in,  under  x-rays,  263 

Cassidy,  225,  226,  318 

Casts,  plaster,  bandages,  and  splints 
in  radiography,  133 

Cathode  rays,  18 

Cervix  uteri,  tube  for  x-ray  treatment 
of,  58 

Childs,441 

Chislett,  488 

Chronic  ulcers,  x-rays  in,  560 

Circuits,  power,  and  electric  light- 
ing, as  sources  of  electrical  energy, 
26 

Clamping  of  x-ray  tubes,  34 

Clark,  246,  468,  469 

Clavicle,  radiography  of,  162 

Clavus,  x-rays  in,  566 

Clemensen,  300 

Clothing  in  radiography,  132 

Codman,  229,  234,  235,  240,  241,  318, 
332 

Coils,  induction,  22,  60.  See  also 
Induction  coil. 

Coley,  246,  515,  517,  574 

Comedo,  x-rays  in,  352 

Condenser  for  interrupters,  85 

Conjunctivitis  from  x-rays,  244 

Centre  mo  ulin's  rotary  interrupter,  71 

Controller,  friction  speed,  for  static 
machine,  105 

Corium,  histological  changes  pro- 
duced in,  by  x-rays,  253,  254 

Corson's  method  of  printing  x-ray 
negatives,  205 

Cossar's  tube  for  therapeutic  uses,  55 

Cowl,  119,  145 

Cowl's  apparatus  for  making  radio- 
graphs, 145 


Cowl's  apparatus  for  supporting  plate 
in    radiographic    exposures    of 
thorax  and  shoulders,  176 
method  of  locating  foreign  bodies 

in  eye,  187 
plate    support    for    radiographing 

thorax  and  shoulder,  161 
Crane's  interrupter,  81 
Crookes,  17 
Crookes'  tubes,  21 
exciting  of,  21 
modifications  of,  21 
tinfoil  electroscope  for  indicating 

potential  at  terminal  of,  39 
Cunningham,  76 

Cunningham's     mercury    jet     inter- 
rupter, 76 
Cutaneous    carcinoma,    scars    after 

x-ray  treatment  of,  410,  467 
x-rays  in,  403 
Cuthbertson,  391 

Cutis,  histological  changes  produced 
in,  by  x-rays,  251 


DALE,  235 

Danlos,  293 

Dark    room    for    developing    x-ray 

plates,  202 

Davis,  393,  426,  538,  539 
Dean's  osmo-regulator  tube,  51 
Deep-seated  carcinoma,  x-rays  in,  502 

pain,  relief  of,  by  x-rays,  233 
Delepine,  280 
Dermatitis,  blastomycetic,  x-rays  in, 

399 

from  x-rays,  223 
chronic,  229 
histology  of,  249 
relapses  in,  238 
Despeignes,  246,  339,  509 
Developers  for  x-ray  plates,  197 
Developing  x-ray  plates,  200 
dark  room  for,  202 
rubber  gloves  for,  204 
Diagraph,  120 

Diaphragms,  adjustable,  116 
Diphtheria,    bacillus    of,    effect    of 
x-rays  on,  279 


580 


INDEX. 


Discharge  of  static  machine,  regulat- 
ing, 104 

Dohring,  451,  549 
Bellinger,  397 
Double-focus  tubes,  54 
Downes  and  Blunt,  300 
Dudley,  471,  510 
Duncan,  404,  405,  510 
Dunton,  425 


ECZEMA,  x-rays  in,  363 

Ehrmann,  340 

Eijkman,  246,  468,  470,  502 

Eisendrath,  546,  549 

Elbow,  radiography  of,  158 

Electrical  action  as  cause  of  x-ray 

effects,  288,  289 
energy,  available  sources  of,  24 
batteries  as  sources  of,  24 
electric  lighting  and  power  cir- 
cuits as  sources,  26 
sources  of,  in  x-ray  exposures  for 

therapeutic  purposes,  319 
Electricity  producing  x-ray  burns,  291 
Electrode,  21 

Electrolysis,  removal  of  hair  by,  348 
Electrolytic  interrupters,  78 
Electroscope,   tinfoil,   for  indicating 
potentials  at  terminals  of  Crookes 
tube,  39 

Electro-static  discharges  in  produc- 
tion of  x-ray  effects,  289 
Elephantiasis,  x-rays  in,  560 
Energy,  electrical,  available  sources 

of,  24 

batteries  as  sources  of,  24 
electric  lighting  and    power  cir- 
cuits as  sources,  26 
sources  of,  in  x-ray  exposures  for 

therapeutic  purposes,  319 
Engman,  413,  418 

Epidermis,  histological  changes  pro- 
duced in,  by  x-rays,  250 
Epithelioma,  scars  after  x-ray  treat- 
ment of,  410,  457 
x-rays  in,  403 

Erythema,     development     of,     after 
x-ray  exposures,  237 


Escherich  de  Graz,  246,  557 
Esophagus,  carcinoma  of,  x-rays  in, 
500 

radiography  of,  176 
Evans,  266,  497 

Exophthalmic  goiter,  x-rays  in,  558 
Extremities,  fluoroscopy  of,  118 
Extremity,    upper,    radiography    of, 

157 

Eye,  foreign  bodies  in,  location  of, 
with  x-rays,  187 

sarcoma  of,  x-rays  in,  530 
Eyes,  effect  of  x-rays  on,  244,  295 

susceptibility  of,  to  x-rays,  244 

treatment  of  surfaces  around,  328 


FACE,   fluoroscopic    examination   of, 
117 

radiography  of,  171,  173 
Favill,  372,  397 
Favus,  x-rays  in,  350 
Femur,  sarcoma  of,  x-rays  in,  515 
Fenger,  431,  471,  472,  475,  483,  491, 

502,  523,  542,  515,  546 
Ferguson,  246,  404,  469 
Finsen,  294,  300 
Fiske,  517,  525,  529 
Fistula,   tuberculous   vesical,   x-rays 

in,  393 
Fitch,  504 
Fluorescent  screens,  27,  112 

apparatus  for  orthographic  pro- 
jection of  shadows  on,  120,  121 
Fluoroscope,  adjustable  diaphragms 
for,  116 

location  of  foreign  bodies  with,  121 
Shenton's  method,  122 

tube,  and  patient,  importance  of 
proper  relation  of,  117 

with  removable  screen,  113 
Fluoroscopes,  112 
Fluoroscopy,  109 

apparatus  for,  109 

limitations,  109 

of  abdomen  and  pelvis,  121 

of  face,  117 

of  head, 117 

of  neck, 117 


INDEX. 


581 


Fluoroscopy  of  shoulder,  118 
of  thorax,  119 
over-exposure  in,  guarding  against, 

116 

screens  for  preventing  burns  in,  117 
spark  gap  in,  110 

Follicles,  sebaceous,  histological 
changes  produced  in,  by  x-rays, 
251 

Foot,  radiography  of,  165 
Foreign    bodies,    location     of,    with 

x-rays,  187 
location  of,  with  fluoroscope,  121 

Shenton's  method,  122 
with  x-rays,  1 83 
Frank,  552,  555,  556 
Freund,  283,  286,  335,  339,  350,  565, 

573,  574 
Fuchs,  234 
Fuller,  522 
Fuses  for  induction  coil,  87 


GAIFFE   and   Galliott's    modification 

of  Wehnelt  interrupter,  82 
Gall-stones,  radiography  of,  180 
Gassmann,  249,  259,  351 
Gassmann  and  Schenkel,  371 
Gautier,  355,  361 
Geissler,  17 
Genito-urinary  tract,  tuberculosis  of, 

x-rays  in,  396 
Gilchrist,  231,  235,  240,  247,  249,  250, 

287 

Gilman,  398 

Glands,  parotid,  sarcoma  of,  x-rays 
in,  516 

tuberculous,  x-rays  in,  393 
Gleason,  505 
Gloves,  rubber,  in  developing  x-ray 

plates,  204 

Gocht,  246,  340,  468,  556 
Goitre,  x-rays  in,  558 
Goodkind,  549 
Granulomata,  x-rays  in,  514 
Gratiot,  472 
Greenleaf,  283,  371 
Grey,  488 
Grouven,  249,  263,  369 


Growths,    malignant,    diagnosis    of, 

radiography  in,  133 
Gundelach's  heavy  target  tube,  50, 

52 


HAHN,  247,  340,  351,  361,  363,  365, 

370 
Hahn    and    Albers-Schonberg,    350, 

364,  371,  398,  558 
Hair,  histological  changes  produced 
in,  by  x-rays,  251 

removal  of,  by  electrolysis,  348 

by  x-rays,  339 
Hall-Edwards,  369,  371 
Halsted,  500,  507 
Hand,  radiography  of,  158 
Hansmann,  294 
Hardie,  414 
Harper,  530 
Harris,  559 
Hart,  560 
Hartley,  413 
Hartman,  496,  497 
Havas,  398 
Head,  carcinoma  of,  x-rays  in,  502 

fluoroscopic  examination  of,  117 

radiography  of,   171 
Health,  general,  effects  of  x-rays  on, 

572 
Heat  in  x-ray  tubes,  production  and 

dissipation  of,  31 
Hektoen,  275 
Hertz,  17,  18 
Hett,  404,  510,  542 
High-frequency  coils,  24 
Hip-joint,  radiography  of,  170 
Hirschmann's  rotary  interrupter,  71 

tube,  51,  52 
Histological     changes    produced     in 

tissues    by  x-rays,  249 
Hittorf,  17 

Hodgkin's  disease,  tumors  in,  spon- 
taneous disappearance  of,  551 

disease,  x-rays  in,  542 
Hoho,  79 
Holland,  371 

Holtz  static  machine,  99-103 
Holzknecht,  119,  175,  341,  348,  349 


582 


INDEX. 


Hopkins,  271,  272,  404,  468,  510 
Huntington,  271 
Hyde,   399 

Hyperidrosis,  x-rays  in,  362 
Hyperkeratosis  from  x-rays,  229 
Hypertrichosis,  electrolysis  in,  348 
x-rays  in,  339 


IDIOSYNCRASIES  to  x-rays,  240 
Illuminating    device    for    negatives, 

146 

Immunity  to  x-rays,  245 
Induction   coil,  22,  60 
action  of,  23 

ammeter  for,  in  x-ray  exposures 
for  therapeutic  purposes,  320 
breakdown  in,  63 
fuses  for,  87 
high-frequency,  24 
installations,  90 
interrupters   for,   65.      See   also 

Interrupters. 

in  .r-ray  exposures  for  therapeu- 
tic purposes,  319 
meter  for,  88 

in  x-ray  exposures  for  thera- 
peutic purposes,  319 
portable,  93 
primary  and  secondary  windings 

in,  insulation  between,  61 
windings  in,  60 
requirements  of,  for  x-ray  work, 

64 

rheostats  for,  86 
secondary,  terminals  in,  insula- 
tion of,  63 

winding  in,  insulation  of,  62 
switches  for,  87 
volt  meter  for,  89 

in  x-ray  exposures  for  thera- 
peutic purposes,  320 
vs.  static  machine  in  x-ray  ex- 
posures  for   therapeutic   pur- 
poses, 317 
Inflammatory  diseases  of  skin,  x-rays 

in,  363 

Influence    machine,    22.       See    also 
Static  machine. 


Installations  of  induction  coil,  90 
Insulation     between     primary     and 
secondary    windings    in    induc- 
tion coil,  61 
of  patient  in  x-ray  exposures  for 

therapeutic  purposes,   330 
of  secondary  terminals   in   induc- 
tion coil,  63 

winding  in  induction  coil,  62 
Intensifying  screens  in  radiography, 

143 

Interrupters,  67 
condenser  for,  85 
electrolytic,  78 
for  induction  coil,  65 
in  x-ray  exposures  for  therapeutic 

purposes,  320 
mercury,  73 
rotary,   70 
tachometer  for,  in  x-ray  exposures 

for  therapeutic  purposes,  320 
turbine,  75 
vibrating,  67 
Intra-abdominal    tumor,    x-rays    in, 

509 
Itching,  x-rays  in,  247 

JACKSON,  17,  20 

Jackson  single  focus  tube,  43 

Johnson  and  Merrill,  246,  317,  403, 
405,  413,  468,  470,  502 

Johnson's  modification  of  Wheat- 
stone's  stereoscope,  193 

Johnston,  230 

Joints,  tuberculosis  of,  x-rays  in,  395, 
396 

Jones,  A.  F.,  504 

Jones,  P.  M.,  286,  297,  371,  372 

Jutassy,  340,  341,  352,  363,  368,  565 

KAPOSI,  271,  272 

Kearsley,  494 

Kelly,    500 

Keratosis,  precancerous,  from  x-rays, 

230 

Kibbe,  249 
j   Kidneys     and     ureters,    stones     in, 

radiography  of,  178 


INDEX. 


583 


Kienbock,  240,  241,  244,  287,  322, 
326,  349,  350 

Kienbock's  technique  of  x-ray  expo- 
sures for  therapeutic  purposes,  302 

King,  241,  244 

Kinraide,  24 

Kirby,  246,  514 

Knee-joint,  radiography  of,  169 

Knox,  371,  372 

Knudson,  426 

Kohl's  mercury  plunger  interrupter, 
74 

Kummell,  330,  339,  371,  398 


LANCASHIRE,  245 
Lanolin  in  x-ray  burns,  332,  333 
Larsen,  300 

Larynx,    tuberculosis   of,    x-rays  in, 
395,  396 

x-ray  treatment  of,  tube  for,  56 
Lead  and  opium  compresses  for  x-ray 
burns,  333 

as  protective  in  using  x-rays,  325 
Lead-foil     as     protective     in     using 

x-rays,  326 
Lee,  368 
Leg,  radiography  of,  166 

tuberculous  ulcer  of,  x-rays  in,  391 
Lehman,  293 
Leigh,  247,  395 
Lenard,  17,  18 
Leonard,  286,  331,  334 
Leprosy,  x-rays  in,  399 
Leprous  tissue,   microscopic  changes 

in,  under  x-rays,  263 
Leucoma,  x-rays  in,  566 
Leukemia,  x-rays  in,  552 
Levy's  mercury  jet  interrupter,  75 
Lewis,  351 

Lichen  plan  us,  x-rays  in,  367 
Light  and  x-rays,  actinic  properties 

of,  similarity  of,  297 
relation  between,  292 

effect  of,  upon  bacteria,  299 

standard,    in   x-ray   exposures   for 

therapeutic  purposes,  309 
Lilienthal,  287 
Localization  in  radiography,  183 


Lortet  and  Genoud,  284,  390 
Lumbar  vertebrae,  radiography  of,  176 
Lumiere,  294 
Lupous  tissue,   microscopic   changes 

in,  under  x-rays,  260 
Lupus  erythematosus,  368 

vulgaris,    cosmetic    excellence    of 
scars   after   x-ray    treatment, 
390 
length  of  treatment  with  x-rays, 

388 
x-rays  in,  371 

character  of  scars  after,  379 
Lyon,  280 


MACKENZIE  Davidson,  171,  184,  190 
Mackenzie    Davidson's    cross-thread 

localizer,  185 
mercury  interrupter,  74 
method  of  locating  foreign  bodies 

with  x-rays,  184 
Mackey,    364 

Malignant  diseases,  prophylactic  use 
of  x-rays  after  operations  for, 
538 

x-rays  in,  403,  568 
growths,  diagnosis  of,  radiography 

in,  133 
Mammary    carcinoma,     primary, 

x-rays  in,  493 
summary,  497 
recurrent,  x-rays  in,  470 

summary.  492 
x-rays  in,  468 
Marquardt,  434 
Mascat,  560 

Masks  in  x-ray  exposures  for  thera- 
peutic purposes,  326,  327 
Matthaei,  383 
Mayo,  493 
Me  Arthur,  226,  397,  406,  503,  525 

529,  546,  549 
McBurney,  470 
McGregor,  445 
McMurtry,  511 

Mediastinal  tumors,  x-rays  in,  499 
Medio-tarsal   joint,   radiography   of, 
165 


584 


INDEX. 


Meek,  340,  364 
Mellish,  540,  541 
Mercury  interrupters,  73 

jet  interrupter,  75,  76,  77 

plunger  interrupter.  73 
Mesenteric    tuberculosis,    x-rays    in, 

397 
Metastasis,  danger  of,  under  x-rays, 

574 
Meter  for  induction  coil,  88 

in  x-ray  exposures  for  thera- 
peutic purposes,  319 
Mica  plates  for  static  machine,  104 
Minck,  279 
Mitchell,  452 
Moisture,  effects  of,  on  static  machine, 

107 

Montgomery,  399 
Moritz,  diagraph  of,   120 
Morton,  246,  404,  468,  470,  509 
Mouth  and  pharynx,  masks  in  making 
x-ray  exposures  of,  327 

carcinoma  of,  x-rays  in,  506 

tube  for  making  x-ray  exposures 

in,  328 
Moyer,  540 
Miiller,  33,  45 
Miiller's  regulating  tube,  49 

tube  with  water-cooled  target,  52 
Miihsam,  285,  391,  396 
Murphy,  406,  451,  496,  497,  499,  502, 

503 
Mycosis  fungoides,  x-rays  in,  531 


N.EVI,  vascular,  x-rays  in,  565 
x-rays  in,  560 

Nails,  changes  in,  in  x-ray  burns,  230 

Neck,  carcinoma  of,  x-rays  in,  502 
fluoroscopic  examination  of,  117 
radiography  of,  171,  174 
sarcoma  of,  x-rays  in,  514 
tuberculous  glands  of,  x-rays  in, 

394,  396 
sinuses  of,  x-ray  treatment,  392 

Necrosis  of  connective  tissue,  x-ray 
burns  with,  duration  of,  239 

Neuralgia,  pain  in,  x-rays  in,  246 

Neuralgias,  x-rays  in,  556 


Newton,  446 

Nitrogen  oxids  and  ozone  in  static 

machine,  106 
Non-malignant    diseases,    x-rays    in, 

567 


OCHSXEIJ,   379,   392,  481,  483,  487, 

494,  498,  504,  518,  523,  531,  532, 

539,  540,  542,  552 
Oiling  static  machine,  107 
Operation,  use  of  x-rays  preliminary 

to,  541,  570 
Orbit,  deep  carcinoma  in,  x-rays  in, 

507 

Orthoform  in  x-ray  burns,  334 
Osier,  500 
Oudin,  306 
Oudin,  Barthelemy,  and  Darier,  232, 

244,  247,  249,  250 
Oudin's   recommendations    of   x-ray 

exposures  for  therapeutic  purposes, 

306 

Over-exposure  in  fluoroscopy,  guard- 
ing against,  116 
Oviatt,  507 
Owen,  406 
Oxid   of   zinc   plaster   as   protective 

against  x-rays,  329 
Ozone  and  nitrogen  oxids  in  static 

machine,  106 


PAGTST,  483 

Pain,  deep-seated,  relief  of,  by  x-rays, 
233 

in  carcinoma,  x-rays  in,  246 

in  neuralgia,  x-rays  in,  246 

in  rheumatism,  x-rays  in,  246 

in  sarcoma,  x-rays  in,  246 

in  x-ray  burns,  226 

increase  of,  after  x-rays,  248 

relief  of,  by  x-rays,  247 

x-rays  in,  247 
Pakhitonov,  355 
Paraffin  as  preventive  of  x-ray 

burns,  288,  329 
Parotid   glands,   sarcoma   of,   x-rays 

in,  516 


INDEX. 


585 


Parotid,  sarcoma  of,  x-rays  in,  523 
Patient,  fluoroscope,  and    tube,  im- 
portance of  proper  relation  of,  117 
Pelvis  and  abdomen,  fluoroscopy  of, 

121 

carcinoma  in,  x-rays  in,  510 
radiography  of,  177 
Penetration    of   x-ray    tubes,    deter- 
mination   of,    Rontgen's     plati- 
num aluminum  window  for,  41 
of  x-ray  tubes,  device  for  measur- 
ing, 40 

Penetrator  tube,  45 
Peritonitis,       chronic       tuberculous, 

x-rays  in,  396 
Permanency  of  results  produced  by 

x-rays,  570 
Pfahler,  246,  404 

Pharynx  and  mouth,  masks  in  mak- 
ing x-ray  exposures  of,  327 
carcinoma  of,  x-rays  in,  506 
Photographic  plates,  27 
Pierce,  418 

Pigmentation  from  x-rays,  222 
Pinchon,  431 
Plante,  78 
Plaster  casts,  bandages,  and  splints 

in  radiography,  133 
Plate,    distance    of    tube    from,    in 

radiography,   132 

Plate-holders  and  envelopes  in  radiog- 
raphy, 141 
Plates  in  radiography,  developers  for, 

198 
developing,  200 

dark  room  for,  202 
rubber  gloves  for,  204 
manipulation  of,  195 
printing  of,  204 
of  static  machine,  104 
photographic,  27 
Platinum  as  cause  of  x-ray  effects, 

287 
Platinum  -  aluminum      window      of 

Rontgen,  41 

Polarity  of  static  machine,  108 
Portable  x-ray  apparatus,  93 
Porter,  406,  409 
Powell    441 


Precancerous  keratosis  from  x-rays, 

230 
Primary  carcinoma  of  breast,  x-rays 

in,  493 

summary,  497 
Prince,  247 

Printing  x-ray  negative,  204 
Prophylactic  use  of  x-rays,  570 

after  operations  for  malignant 

diseases,  538 
Protectives   in   x-ray   exposures   for 

therapeutic  purposes,  325 
Prurigo,  x-rays  in,  370 
Pruritus,  x-rays  in,  557 
Pseudo-leukemia,    tumors   in,    spon- 
taneous disappearance  of,  551 
x-rays  in,  542 
Psoriasis,    microscopic    changes    in, 

under  x-rays,  259 
x-rays  in,  365 
Pulmonary    tuberculosis,    x-rays    in, 

397 
Punctures  of  x-ray  tubes,  37 


QUALITY  of  x-rays,  factors  affecting, 

308 
Quine,  446 

RACK,  for  supporting  tubes,  fluoro- 
scopes,  etc.,  114 

Radiography,  128 

and     bandages,     splints,     plaster 

casts  in,  133 
clothing  in,  132 
definition  in,  134 
degree  of  penetration,  134 
diagnosis  of  malignant  growths  by, 

133 

distance  of  tube  from  plate  in,  132 
duration  of  exposure  in,  131 
envelopes  and  plate-holders  in,  140 
exciting  apparatus  for,   128 
illuminating  device  in,  146 
importance  of  correct  pose  in,  146 
intensifying  screens  in,  143 
localization  in,   183 
marking  skin  in,  133 


586 


INDEX. 


Radiography,    negatives  in,  examin- 
ing, 156 

interpretation,  194 

marking,  148 

preserving,  156 
of  abdomen,  177 
of  ankle,  165 
of  arm,  160 

of  both  sides  for  comparison,  132 
of  clavicle,  162 
of  elbow,  168 
of  esophagus,  176 
of  face,  171,  173 
of  foot,  165 
of  gall-stones,  180 
of  hand,  158 
of  head,  171 
of  hip-joint,  170 
of  knee-joint,   169 
of  leg,  166 

of  lumbar  vertebra',  176 
of  medio-tarsal  joint,   165 
of  neck,  171,  174 
of  pelvis,  177 
of  shoulder-blade,    162 
of  shoulder-joint,  160 
of  skull,   171 
of  spinal  column,  176 
of  stones  in  bladder,  178 

kidneys  and  ureters,  178 
of  teeth,  173 
of  thigh,  170 
of  thorax,  174 

position  of  patient  in,   176 
of  upper  extremity,  157 
plates  in,  developers  for,  198 

developing,  200 

dark  "room  for,  202 
rubber  gloves  for,  204 

manipulation  of,   195 

printing  of,  204 
prevention    of    movement    during 

exposure,  144 
record  book  in,   150 
secondary  rays,  134 
stereoscopic,  190 
tables  for,  138 
tube-holders  in,  135 
tubes  for,  133 


Ravillet,  395 

Record  book  in  radiography,  150 

of  x-ray  exposures  for  therapeutic 

purposes,  312 

Rectum    and     anus,    carcinoma    of, 
x-rays  in,  513 

tube   for  making  x-ray  exposures 

in,  328 
Recurrent      carcinoma      of      breast, 

x-rays  in,  470 
summary,  492 
Relapses  in  dermatitis  from  x-rays, 

238 

Rendu  and  Du  Castel,  339 
Retinitis  from  x-rays,  244 
Rheostats,  86 
Rheumatism,  pain  in,  x-rays  in,  246 

x-rays  in,  557 
Richardson,  504 
Ricketts,  246,  514 
Rickey,  446 
Rieder,  119,  175,  278 
Rinehart,  351,  404 
Roan,  522 
Roberts,  180 

Rodent  ulcer,  x-rays  in,  405 
Rontgen,  17,  18,  20,  295,  326 
Rontgen's   platinum-aluminum   win- 
dow, 41 

Rollins,  32,  103,  232,  291 
Room,    dark,    for    developing   x-ray 

plates,   202 

Rosacea,  x-rays  in,  361 
Rotary  interrupters,  70 
Rubber  gloves  in  developing  x-ray 

plates,  204 

Rudis-Jicinsky,  279,  398 
Ruediger,  535 
Ruhmer,  84 


SALAMON,  249 

Sarcoma  of  eye,  x-rays  in,  530 
of  parotid,  x-rays  in,  523 
pain  in,  x-rays  in,  246 
x-rays  in,  514 

Sayen  tube,  46 

Sayen's  self-regulating  tube,  46 

Scapula,  radiography  of,  162 


INDEX. 


587 


Scars,  character  of,  in  lupus  vulgaris, 

after  x-ray  treatment,  379 
excellence    of,    after   x-ray    treat- 
ment of  cutaneous  car- 
cinoma, 410,  467 
of  lupus  vulgaris,  390 
from  x-ray  burns,  226 

Schein,  340,  350,  351 

Schenkel,  351 

Scherer,  244 

Schiff,  286,  339 

Schiff  and  Freund,  291,  308,  326,  331, 
340,  350,  351,  363,  368,  371,  390 

Schiff  and  Freund's  technique  of 
x-ray  exposures  for  therapeutic 
purposes,  308 

Scholeneld,  371 

Scholtz,  233,  244,  245,  247,  249,  252, 
259,  260,  263,  285,  287,  305,  322, 
351,  355,  361,  364,  366,  367,  369, 
370,  389,  396,  399,  404,  531,  557, 
566 

Scholtz's  technique  of  .r-ray  expo- 
sures for  therapeutic  purposes, 
305 

Scott,  22,  231,  235,  236,  240 

Screens,   aluminum,   in   .r-ray   expo- 
sures for  therapeutic   purposes, 
329 
fluorescent,  27,  112 

apparatus  for  orthographic  pro- 
jection of  shadows  on,  120,  121 
for  preventing  burns  in  fluoroscopy, 

117 
intensifying,  in  radiography,  143 

Scrofuloderma,  x-rays  in,  390 

Sebaceous  follicles,  histological 
changes  produced  in,  by  x-rays, 
251 

Sederholm,  340 

Senile  verruca,  x-rays  in,  566 

Senn,  504,  523 

Sensibility,  loss  of,  from  x-rays,  247 

Sequeira,  226,  246,  271,  283,  399, 
404 

Shadows  on  fluorescent  screen,  ap- 
paratus for  orthographic  projec- 
tion of,  120,  121 

Sharpe,  271,  322,  340 


Sheet-lead    as    protective    in    using 

x-rays,  326 
Sheldon,  475 
Shenton's  method  of  locating  foreign 

bodies  with  fluoroscope,  122 
of  making  radiographs  of  kidney, 

179 
table   with    movable    tube-holder, 

140 

Shoulder,  fluoroscopy  of,  1 18 
Shoulder-blade,  radiography  of,  162 
Shoulder-joint,  radiography  of,  160 
Sight,  effect  of  x-rays  upon,  295 
Sinapius,  398 
Sinuses,  callous,  x-rays  in,  560 

tuberculous,  of  neck,  x-ray  treat- 
ment, 392 

Sjogren,  340,  368,  403,  405 
Sjogren    and    Sederholm,    341,    355, 
364,  365,  369,  392,  404,  405,  557, 
560,  566 

Skin,  after-effects  of  x-rays  on,  225 
appendages   of,   changes   in,   from 

x-rays,  230 

diseases  of,  x-rays  in,  339 
carcinoma  of,  x-rays  in,  403 
condition  of,  after  x-ray  treatment 

of  acne,  360 
of  hypertrichosis,  348 
effect  of  x-rays  on,  222 
inflammatory    diseases    of,    x-rays 

in,  363 

marking,  in  radiography,  133 
Skinner,  517 

Skull,  radiography  of,  171 
Smith,  404,  413 
Soiland,  246,  468,  469 
Sokolow,  246,  557 
Spark  gap  in  fluoroscopy,  110 
of  static  machine,  108 
Williams,  110 

in  x-ray  exposures  for  thera- 
peutic purposes,  306 
Speed  controller,  friction,  for  static 

machine,  105 
Spiegler,  351 

Spinal  column,  radiography  of,  176 
Splints,  bandages,  and  plaster  casts 
in  radiography,  133 


588 


INDEX. 


Spottiswoode,  78 

Sprague,  508 

Standard  light  in  x-ray  exposures  for 

therapeutic  purposes,  309 
Startin,  283,  340,  365,  368,  371,  404 
Static  machine,  22 

effects  of  moisture  on,  107 
enclosing  case  for,  106 
friction  speed  controller  for,  105 
management  of,  98 
oiling  of,  107 

ozone  and  nitrogen  oxids  in,  106 
plates  of,  104 
polarity  of,  108 
regulating  discharge  of,  104 
size  of,  103 
spark  gap  of,  108 
vs.   induction   coil   in  x-ray   ex- 
posures  for   therapeutic   pur- 
poses, 317 

Steele,  358,  491,  550 
Stein,  506 
Stembo,  246,  556 
Stenbeck,  403,  404,  405 
Stereo-fluoroscopy,  124 
Stereoscope,  193 
Stereoscopic  radiographs,  190 
Sterne,  573 
Stevens,  529 
Stinson,  235 
Stokes,  293 
Stomach,    carcinoma   of,   x-rays   in, 

509 
Stones   in   bladder,   radiography   of, 

178 

in  gall-bladder,  radiography  of,  180 
in  kidneys  and  ureters,  radiography 

of,  178 

Storage  batteries  as  source  of  elec- 
trical energy,  25 
Strater,  365 
Stuver,  510 
Sunstroke,     symptoms     similar     to, 

from  x-rays,  233 
Suppurating   ulcer,   effect   of  x-rays 

on,  283 
Susceptibility   of   different    parts   of 

body  to  x-rays,  243,  244 
of  eyes  to  x-rays,  244 


Susceptibility  to  x-rays,  factors  af- 
fecting, 245 

preliminary  exposure   to   deter- 
mine, 311 
variations  in,  243 
Sweat-glands,      atrophy      of,     from 

x-rays,  362 
Swinton,  84 

Switches  for  induction  coil,  87 
Sycosis,    cessation    of    discharge    in, 

from  x-rays,  283 
x-rays  in,  351 

reaction    necessary    to    be    pro- 
duced in,  352 

Syphilides,  tubercular,  x-rays  in,  399 
Syphilis,  x-rays  in,  398 
Syphilitic  ulcers,  x-rays  in,  399 


TABLES  for  radiography,  138 
Tachometer  for  interrrupter   coil   in 

x-ray    exposures     for   therapeutic 

purposes,  320 
Target,  21 

Taylor,  322,  404,  558 
Teeth,  radiography  of,  173,  196 
Temperature  of  x-ray  tubes,  34 
Tesla,  24,  286,  330 
Testing  x-ray  tubes,  38 
Thigh,  radiography  of,  170 
Third,  404 
Thoma,  275 
Thompson,  293 

Thomson,  232,  286,  287,  288,  289,  329 
Thomson's  double-focus  tube,  54 

vacuum  regulator  tube,  45 
Thorax,  carcinoma  in,  x-rays  in,  468 

fluoroscopy  of,  119 

radiography  of,  174 

position  of  patient  in,  176 
Tinea  tonsurans,  x-rays  in,  350 
Tinfoil  electroscope  for  indicating 

potential  at   terminal    of   Crookes 

tube,  39 
Tinker,  485 

Tissues  changes  in,  after  exposure  to 
x-rays,      active     agent 
causing,  286 
causes  of,  286 


INDEX. 


589 


Tissues,  connective,  necrosis  of,  x-ray 

burns  with,  duration  of,  239 
deep,  effects  of  x-rays  on,  231 
effects  of  x-rays  on,  221 
cumulative,  239 
symptoms  of,  times  of  first  ap- 
pearance, 234 
histological   changes   produced   in, 

by  x-rays,  249 

property  in  x-rays  that  affects,  292 
x-ray   effects   upon,   time  of  first 

appearance  of  symptoms,  234 
Toepler-Holtz    static    machine,    99, 

100,  102,  103 

Tonsil,  sarcoma  of,  x-rays  in,  515 
Torok,  350,  351 

Torok  and  Schein,  355,  369,  370 
Tube,  bario-vacuum,  and  regulator, 

46 

bi-anode,  44 
choice  of,  43 

Cossar's,  for  therapeutic  uses,  55 
Dean's,  51 

distance  of,  from  plate,  in  radiog- 
raphy, 132 

in  x-ray  exposures  for  therapeu- 
tic purposes,  311 

fluoroscope,   and    patient,    impor- 
tance of  proper  relation  of,  117 
for  x-ray  treatment,  for  use  with 

shield,  57 
for  x-ray  treatment  of  cervix  uteri, 

58 

for  x-ray  treatment  of  larynx,  56 
Hirschmann's,  51,  52 
Jackson,  43 
Miiller's,  49 

with  water-cooled  target,  52 
penetrator,  45 
Sayen,  46 
Thomson's,  45 

double-focus,  54 
Volt-Ohm,  53 

Tube-holders  in  radiography,  135 
in  x-ray  exposures  for  therapeutic 

purposes,  320 
Tubercle  bacilli,  effect  of  x-rays  on, 

281,  284 
Tubercular  syphilides,  x-rays  in,  399 


Tuberculosis,   abdominal,   x-rays  in 

396 

mesenteric,  x-rays  in,  397 
of  genito-urinary  tract,  x-rays  in, 

396 

of  joints,  x-rays  in,  395,  396 
of  larynx,  x-rays  in,  395,  396 
pulmonary,  x-rays  in,  397 
x-rays  in,  371 

Tuberculous  glands,  x-rays  in,  393 
peritonitis,  chronic,  .r-rays  in,  396 
sinuses  of  neck,  x-ray  treatment, 

392 

ulcers,  x-rays  in,  390 
vesical  fistula,  x-rays  in,  393 
Tubes,  clamping  of,  34 
connecting  wires  of,  34 
Crookes,  21 

exciting  of,  21 

modifications  of,  21 

tinfoil  electroscope  for  indicating 

potential  at  terminal  of,  39 
definition,  29 
double-focus,  54 
for  radiography,  133 
for  therapeutic  uses,  55 
general  properties,  29 
heat  in,  production  and  dissipation 

of,  31 
in  x-ray  exposures  for  therapeutic 

purposes,  321 
operation  of,  33 
penetration  of,  30 

determining,  Rontgen's  plat- 
inum-aluminum window  for, 
41 

device  for  measuring,  40 
punctures  of,  37 
quality  of,  for  x-ray  exposures  in 

therapeutic  work,  310 
selection  of,  for  pathological  con- 
ditions, 322 

for  x-ray  work,  214 
temperature  of,  34 
testing  of,  38 
water-cooled,  52 
with  heavy  targets,  52 
with  osmosis  regulators,  50 
with  vacuum  regulators,  45 


590 


INDEX. 


Tumors    in    pseudo-leukemia,    spon- 
taneous disappearance  of,  551 

mint-abdominal,  x-rays  m,  509 

mediastinal,  x-rays  in,  499 

of  breast,  x-rays  in,  498 
Turbine  interrupters,  75 
Typhoid  fever,  bacillus  of,  effect  of 

x-rays  on,  279 


ULCERS,  chronic,  x-rays  in,  560 
rodent,  x-rays  in,  405 
suppurating,   effect   of  x-rays   on, 

283 

syphilitic,  x-rays  in,  399 
tuberculous,  x-rays  in,  390 
x-ray,  histological  findings  in,  256 

Ullman,  285,  363,  558 

Unna,  249,  252 

Ureters  and  kidneys,  stones  in,  radi- 
ography of,  178 

Urticaria  pigmentosa,  x-rays  in,  370 

Uterus,  carcinoma  of,  x-rays  in,  510, 
511 


VAGINA,  mask  in  making  x-ray  ex- 
posure through,  327 
tube  for  making  x-ray  exposures 

in,  328 

Vascular  nsevi,  x-rays  in,  565 
Vaselin  and  boric  acid  in  x-ray  burns, 

333 
as  protective  against  x-ray  burns, 

288,  329 
Verruca,  senile,  x-rays  in,  566 

x-rays  in,  566 
Vertebrae,    lumbar,    radiography   of, 

176 
Vesical    fistula,    tuberculous,   x-rays 

in,  393 

Vibrating  interrupters,  67 
Villard,  324 

Voltage  and  amperage,  influence  of, 
in  x-ray  exposures  for  therapeutic 
purposes,  310 
Volt  meter,  89 

in    x-ray   exposures    for    thera- 
peutic purposes,  320 


Volt-Ohm  tube,  53 

Vomiting  after  x-ray  exposures,  232 

Von  Ziemssen,  119,  175 

Vril  vibrating  interrupter,  69 


WALKER,  531 

Walsh,  233,  340 

Water-cooled  tubes,  52 

Wehnelt's  interrupter,  79,  81 

Weigel's  modification  of  Wheat- 
stone's  stereoscope,  193 

Westcott,  432 

Wheatstone  stereoscope,  193 

White,  230 

Wilder,  507 

Wilkinson's  spark  gap,  112 

Williams,  103,  117,  119, 175, 177,  306, 
326,  363,  366,  391,  392,  393,  404, 
468,  514,  542,  558,  566 

Williams'  box,  325 

series  spark  gap,  110,  306 
technique   of  x-ray   exposures   for 

therapeutic  purposes,  306 
tube-box,  326 

Wimshurst  static  machine,  99,  100, 
103 

Winton,  511 

Wires,  connecting,  of  x-ray  tubes,  34 

Wittlin,  279 

Wolfenden  and  Forbes-Ross,  280 

Wood,  340,  341,  531 

Wrist,  radiography  of,  158 

Wylie,  226 


X-RAY  apparatus,  portable,  93 
equipment,  essentials  of,  21 
exposures,  effects  from,  314 

for  therapeutic  purposes,  alumi- 
num screen  in,  329 
apparatus,  317 

necessary,  312 
distance  in,  311 
duration  of,  311 
energy,  source  of,  319 
frequency  of,  311 
induction  coil  in,  319 
ammeter  for,  320 


INDEX. 


591 


X-ray  exposures  for  therapeutic  pur- 
poses, induction  coil 
in,  interrupters  for, 
320 

meter  for,  319 
tachometer  for,  320 
volt  meter  for,  320 
vs.  static  machine,  317 
influence  of  amperage  and 

voltage  in,  310 
insulation  of  patient  in,  330 
masks  in,  326,  327 
preliminary,    to    determine 

susceptibility,  311 
protectives  in,  325 
record  of,  312 
standard  light  in,  309 
technique  of,  302 
tube  in,  distance  of,  311 
tube-holders  in,  320 
tubes  for,  321 

quality  of,  310 
outfit,  choice  of,  208 
shadows  on  fluorescent  screen,  ap- 
paratus for  orthographic  projec- 
tion of,  120,  121 
tube,  choice  of,  43.    See  also  Tube. 


X-ray  tubes,  28.    See  also  Tubes. 
X-rays  and  light,  actinic  properties 

of,  similarity  of,  297 
relation  between,  292 

discovery  of,  17 

exposures  to,  dangerous  and  safe, 
241 

indications  for  therapeutic  use  of, 
335 

length  of  treatment  with,  in  suc- 
cessful cases,  571 

permanency  of  results  from,  570 

quality  of,  factors  affecting,  308 

reasons    for    different    results    in 
similar  cases  with,  571 

use  of  other  treatment  in  conjunc- 
tion with,  575 

use  of,  preliminary  to  operation, 
541,  570 

YOUNG,  486 

ZECHMEISTER,  351 
Zeisler,  566 
Zeit,  280,  518,  522 
Zinc    oxid     as     protective     against 
x-rays,  329 


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GYNECOLOGY  AND    OBSTETRICS. 


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pnce,  however,  remains  unchanged. 


PERSONAL  AND   PRESS  OPINIONS 


Alex.  J.  C.  Skene,  M.  D,. 

Late  Professor  of  Gynecology,  Long  Island  College  Hospital,  Brooklyn. 

"  Permit  me  to  say  that  '  The  American  Text-Book  of  Obstetrics  '  is  the  most  magnificent 
medical  work  that  I  have  ever  seen.  I  congratulate  you  and  thank  you  for  this  superb  work, 
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Matthew  D.  Mann,  M.  D.. 

Professor  of  Obstetrics  and  Gynecology  in  the  University  of  Buffalo. 

"  I  like  it  exceedingly  and  have  recommended  the  first  volume  as  a  text-book  for  our 
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American  Journal  of  the  Medical  Sciences 

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Borland's 
Modern   Obstetrics 


Modern  Obstetrics:  General  and  Operative.  By  W.  A.  NEWMAN 
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Davis*  Obstetric  and 

Gynecologic  Nursing 

Obstetric  and  Gynecologic  Nursing.  By  EDWARD  P.  DAVIS,  A.  M., 
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knowledge  and  experience  in  the  care  of  the  patient  and  child.  Gynecologic 
nursing  is  really  a  branch  of  surgical  nursing,  and  as  such  requires  special 
instruction  and  training.  This  volume  presents  this  informatiou  in  the  most  con- 
venient form. 

The  Lancet,  London 

"  Not  only  nurses,  but  even  newlv  qualified  medical  men,  would  learn  a  great  deal  by  a 
perusal  of  this  book.  It  is  written  in  a  clear  and  pleasant  style,  and  is  a  work  we  can  recom- 
mend." 


GYNECOLOGY  AND    OBSTETRICS. 


Schaffer  and  Edgar's 

Labor  and  Operative  Obstetrics 

Atlas  and  Epitome  of  Labor  and  Operative  Obstetrics.     By  DR. 

O.  SCHAFFER,  of  Heidelberg.  From  the  Fifth  Revised  and  Enlarged 
German  Edition.  Edited,  with  additions,  by  J.  CLIFTON  EDGAR,  M.  D., 
Professor  of  Obstetrics  and  Clinical  Midwifery,  Cornell  University  Medi- 
cal School,  New  York.  With  14  lithographic  plates  in  colors,  139  other 
illustrations,  and  1 1 1  pages  of  text.  Cloth,  $2.00  net.  In  Saunders1 
Hand- Atlas  Scries. 

This  book  presents  the  act  of  parturition  and  the  various  obstetric  operations 
in  a  series  of  easily  understood  illustrations,  accompanied  by  a  text  treating  the 
subject  from  a  practical  standpoint.  The  author  has  added  many  accurate  repre- 
sentations of  manipulations  and  conditions  never  before  clearly  illustrated. 

American  Medicine 

"  The  method  of  presenting  obstetric  operations  is  admirable.  The  drawings,  representing 
original  work,  have  the  commendable  merit  of  illustrating  instead  of  confusing.  It  would  be 
difficult  to  find  one  hundred  pages  in  better  form  or  containing  more  practical  points  for 
students  or  practitioners." 

Schaffer  and  Edgar's 

Obstetric  Diagnosis  and  Treatment 

Atlas  and  Epitome  of  Obstetric  Diagnosis  and  Treatment.     By 

DR.  O.  SCHAFFER,  of  Heidelberg.  From  the  Second  Revised  German 
Edition.  Edited,  with  additions,  by  J.  CLIFTON  EDGAR,  M.  D.,  Professor 
of  Obstetrics  and  Clinical  Midwifery,  Cornell  University  Medical  School, 
N.  Y.  With  122  colored  figures  on  56  plates,  38  text-cuts,  and  315 
pages  of  text.  Cloth,  $3.00  net.  In  Saunders1  Hand-Atlas  Series. 

This  book  treats  particularly  of  obstetric  operations,  and,  besides  the  wealth 
of  beautiful  lithographic  illustrations,  contains  an  extensive  text  of  great  value. 
This  text  deals  with  the  practical,  clinical  side  of  the  subject.  The  symptoma- 
tology and  diagnosis  are  discussed  with  all  necessary  fullness,  and  the  indications 
for  treatment  are  definite  and  complete. 

New  York  Medical  Journal 

"The  illustrations  are  admirably  executed,  as  they  are  in  all  of  these  atlases,  and  the  text 
can  safely  be  commended,  not  only  as  elucidatory  of  the  plates,  but'as  expounding  the  scien- 
tific midwifery  of  to-day." 


io  SAUNDERS   BOOKS   ON 

Galbraith's 
Four  Epochs  of  Woman's  Life 

The  Four  Epochs  of  Woman's  Life :  A  STUDY  IN  HYGIENE.     By 

ANNA  M.  GALBRAITH,  M.  D.,  author  of  "  Hygiene  and  Physical  Cul- 
ture for  Women"  ;  Fellow  of  the  New  York  Academy  of  Medicine,  etc. 
With  an  Introductory  Note  by  JOHN  H.  MUSSER,  M.  D.,  Professor  of 
Clinical  Medicine,  University  of  Pennsylvania.  I2mo  volume  of  200 
pages.  Cloth,  $1.25  net. 

MAIDENHOOD,  MARRIAGE,  MATERNITY,  MENOPAUSE 

In  this  instructive  work  are  stated,  in  a  modest,  pleasing,  and  conclusive  manner, 
those  truths  of  which  every  woman  should  have  a  thorough  knowledge.  Written, 
as  it  is,  for  the  laity,  the  subject  is  discussed  in  language  readily  grasped  even  by 
those  most  unfamiliar  with  medical  subjects. 

Birmingham  Medical  Review,  England 

"  We  do  not  as  a  rule  care  for  medical  books  written  for  the  instruction  of  the  public.  But 
we  must  admit  that  the  advice  in  Dr.  Galbraith's  work  is  in  the  main  wise  and  wholesome." 

American  Year-Book 

Saunders'  American  Year=Book  of  Medicine  and  Surgery.     A 

Yearly  Digest  of  Scientific  Progress  and  Authoritative  Opinion  in  all 
Branches  of  Medicine  and  Surgery,  drawn  from  journals,  monographs, 
and  text-books  of  the  leading  American  and  foreign  authors  and  inves- 
tigators. Arranged,  with  critical  editorial  comments,  by  eminent  Ameri- 
can specialists,  under  the  editorial  charge  of  GEORGE  M.  GOULD,  A.  M., 
M.  D.  In  two  volumes  :  Vol.  I. — General  Medicine,  octavo,  715  pages, 
illustrated;  Vol.  II. — General  Surgery,  octavo,  684  pages,  illustrated. 
Per  vol. :  Cloth,  $3.00  net ;  Half  Morocco,  $3.75  net.  Sold  by  Sub- 
scription. 

EQUIVALENT  TO   A   POST-GRADUATE   COURSE 

The  contents  of  these  volumes  is  much  more  than  a  compilation  of  data.  The 
extracts  are  carefully  edited  and  commented  upon  by  eminent  specialists,  the 
reader  thus  obtaining  also  the  invaluable  annotations  and  criticisms  of  the  editors, 
all  leaders  in  their  several  specialties.  The  Year- Book  is  amply  illustrated. 

The  Lancet,  London 

"  It  is  much  more  than  a  mere  compilation  of  abstracts,  for,  as  each  section  is  entrusted  to 
experienced  and  able  contributors,  the  reader  has  the  advantage  of  certain  critical  commen- 
taries and  expositions  .  .  .  proceeding  from  writers  fully  qualified  to  perform  these  tasks." 


GYNECOLOGY  AND    OBSTETRICS.  u 

Schaffer  and  Norris' 
Gynecology 

Atlas  and  Epitome  of  Gynecology.  By  DR.  O.  SCHAFFER,  of 
Heidelberg.  From  the  Second  Revised  and  Enlarged  German  Edition. 
Edited,  with  additions,  by  RICHARD  C.  NORRIS,  A.  M.,  M.  D.,  Gynecolo- 
gist to  Methodist  Episcopal  and  Philadelphia  Hospitals.  With  207 
colored  figures  on  90  plates,  65  text-cuts,  and  308  pages  of  text. 
Cloth,  $3.50  net.  /;/  Saunders'  Hand-Atlas  Series. 

The  value  pf  this  atlas  to  the  medical  student  and  to  the  general  practitioner 
will  be  found  not  only  in  the  concise  explanatory  text,  but  especially  in  the  illus- 
trations. The  large  number  of  colored  plates,  reproducing  the  appearance  of 
fresh  specimens,  give  an  accurate  mental  picture  and  a  knowledge  of  the  changes 
induced  by  disease  of  the  pelvic  organs  that  cannot  be  obtained  from  mere 
description. 

American  Journal  of  the  Medical  Sciences 

"  Of  the  illustrations  it  is  difficult  to  speak  in  too  high  terms  of  approval.  They  are  so 
clear  and  true  to  nature  that  the  accompanying  explanations  are  almost  superfluous.  We 
commend  it  most  earnestly." 

Hirst's  Diseases  of  Women 


A  Text- Book  of  Diseases  of  Women.  By  BARTON  COOKE  HIRST, 
M.  D.,  Professor  of  Obstetrics  in  the  University  of  Pennsylvania. 
Handsome  octavo  volume  of  about  800  pages,  magnificently  illus- 
trated. In  Preparation. 

This  new  work  of  Dr.  Hirst's  will  be  on  the  same  lines  as  his  Text-Book  of 
Obstetrics.  The  wealth  of  illustrations  will  be  entirely  original  from  photographs 
and  water-colors  made  especially  for  this  work. 

Webster's  Obstetrics 

A  Text-Book  of  Obstetrics.  By  J.  CLARENCE  WEBSTER,  M.  D., 
F.  R.  C.  P.  K,  Professor  of  Obstetrics  and  Gynecology,  Rush  Medical 
College,  in  affiliation  with  the  University  of  Chicago,  etc.  Handsome 
octavo  volume  of  900  pages,  finely  illustrated.  In  Preparation. 

This  is  an  entirely  new  work  by  an  eminent  teacher  of  wide  experience. 
The  book  will  be  thoroughly  practical  and  the  text  magnificently  illustrated. 


SAUXDERS'    BOOKS    ON 


American  Pocket  Dictionary  Third  Revised  Edition 

THE  AMERICAN  POCKET  MEDICAL  DICTIONARY.  Edited  by  W. 
A.  NEWMAN  BORLAND,  A.M.,  M.  D.,  Assistant  Obstetrician  to  the 
Hospital  of  the  University  of  Pennsylvania;  Fellow  of  the  American 
Academy  of  Medicine.  Over  500  pages.  Full  leather,  limp,  with 
gold  edges.  $1.00  net;  with  patent  thumb  index,  81.25  net. 

James  W.  Holland,  M.  D., 

Professor  of  Medical  Chemistry  and  Toxicology,  and  Dean,  Jefferson  Medical  College, 

Philadelphia. 

"  I  am  struck  at  once  with  admiration  at  the  compact  size  and  attractive  exterior.  I 
can  recommend  it  to  our  students  without  reserve." 

Long's  Syllabus  of  Gynecology 

A  SYLLABUS  OF  GYXECOLOGY,  arranged  in  conformity  with 
"American  Text-Book  of  Gynecology."  By  J.  W.  LONG,  M.  D., 
Emeritus  Professor  of  Diseases  of  Women  and  Children,  Medical 
College  of  Virginia,  etc.  Cloth,  interleaved,  $1.00  net. 

Brooklyn  Medical  Journal 

"  The  book  is  certainly  an  admirable  resume  of  what  every  gynecological  student  and 
practitioner  should  know,  and  will  prove  of  value." 

Cragin's  Gynecology.  Fifth  Revised  Edition 

ESSENTIALS    OF    GYNECOLOGY.     By  EDWIN  B.  CRAGIN,  M.  D., 

Professor  of  Obstetrics,  College  of  Physicians  and  Surgeons,  New 

York.     Crown  octavo,  200  pages,  62  illustrations.     Cloth,  $1.00 

net.     In  Sannders'   Qucstion-Compend  Series. 

The  Medical  Record,  New  York 

"  A  handy  volume  and  a  distinct  improvement  on  students'  compends  in  general. 
No  author  who  was  not  himself  a  practical  gynecologist  could  have  consulted  the 
student's  needs  so  thoroughly  as  Dr.  Cragin  has  done." 

Boisliniere's   Obstetric   Accidents,   Emergencies,   and 
Operations 

OBSTETRIC  ACCIDENTS,  EMERGENCIES,  AND  OPERATIONS.  By 
the  late  L.  CH.  BOISLINIERE,  M.  D.,  Emeritus  Professor  of  Ob- 
stetrics, St.  Louis  Medical  College  ;  Consulting  Physician,  St.  Louis 
Female  Hospital.  381  pages,  illustrated.  Cloth,  $2.00  net. 

British  Medical  Journal 

"  It  is  clearly  and  concisely  written,  and  is  evidently  the  work  of  a  teacher  and  practi- 
tioner of  large  experience.  Its  merit  lies  in  the  judgment  which  comes  from  experience." 


Obstetrics.  Fifth  Edition,  Revised  and  Enlarged 

ESSENTIALS  OF  OBSTETRICS.  By  W.  EASTERLY  ASHTON,  M.D., 
Professor  of  Gynecology  in  the  Medico-Chirurgical  College,  Phila- 
delphia. Crown  octavo,  252  pages,  75  illustrations.  Cloth,  $1.00 
net.  /;/  Saunders'  Question-  Compend  Series. 

Southern  Practitioner 

"  An  excellent  little  volume  containing  correct  and  practical  knowledge.     An   admir- 
able compend,  and  the  best  condensation  we  have  seen." 


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